from the editor Ð dr jackie jones rn phd Ôsoul ... - ajan · australian journal of advanced...

Australian Journal of Advanced Nursing 2006 Volume 24 Number 14

EDITORIAL

Having just enjoyed the debates at the InternationalAcademy of Nursing Editors (INANE) meetingwhere many of the delegates were from North

America I find myself writing this Editorial amidst fearsof a major terrorist plot to blow up aircraft leavingHeathrow London for the United States of America Such terrorists are said to be selling their soul for theirlsquospiritualrsquo cause Nurses on the other hand make it theircause to help people in times of spiritual distress As oneof our papers in this edition suggests (Day) interventionsby health professionals such as cardiac rehabilitation are said to promote spiritual recovery but what constitutesrecovery of the spirit and how does one therefore feed the soul Not all individuals relate spirituality to religionnor do they consider themselves very spiritual Howeverspiritual lsquoawakeningrsquo is said to occur particularly in theface of adversity illness disease and mental illness Manynurses may on reading this question what this has to do with lsquorealrsquo practice Others will nod because they have been lsquoawakenedrsquo spiritually through their practice asnurses and encounters with patients Yet others willconsider themselves very spiritual in general or throughformalised religious beliefs

Even the most cursory glance at the literature revealsspirituality as a growth area of nursing research Keyissues arising from this body of work include a lack ofclarity in terminology language and definitions and aclash with the personal values and comfort level of nursesthemselves This clash of values and comfort level ofnurses around spirituality can be problematic

For example in a recent research paper Wilding et al(2006) describe some of the perceived boundaries betweenmental illness and spirituality and the consequences ofnegative stereotypes and prejudice by health professionalsas experienced by mental health patients Hearing voicescould be consistent with a psychotic episode or consistentwith acknowledging onersquos own spiritual guidance Is thisspiritual element of being human still taboo and hidden ina similar manner to that of being named a healer (nurse)in one century or a witch in another dependent on thepolitics and prevailing discourses of the time Participantsin the Wilding study described a uniquely experiencedjourney of spiritual beliefs where lsquoprofound changes can occur particularly following profound experiencesrsquo(Wilding et al 2006 p151) This journey was consideredto be life-sustaining and therefore vital to the participantsrsquoongoing wellbeing

Returning again to the notion of relevance to practice itis important to highlight that the Australian Nursing and Midwifery Council states that a registered nurselsquofacilitates a physical psychosocial cultural and spiritualenvironment that promotes individualgroup safety and

securityrsquo (ANMC 2006) Wilding et al advocate healthprofessionals lsquotake a wide and inclusive view of whatspirituality can be (2006 p150)rsquo reminding us that theseviews do not remain static and therefore the lsquofood for thesoulrsquo that is needed at a particular time also varies Being self reflective of ones own spiritual beliefs and the relationships between spirituality and client care isincreasingly important Whether nurses have yet realisedits importance against a backdrop of relentless technologicalgrowth and change our prevailing discourses remain to be seen

Listening carefully to clients and moving away from alsquoone size fits allrsquo approach to care dimensions will beneeded if nurses are to hear what a person values abouttheir life and the care they believe they need in theirencounters with the system Nurses need also to recognisethat some aspects of a patientrsquos value system may meanpatients are afraid to share their values with those caringfor them Nurses are constantly being challenged by theneeds and beliefs of those around them they alsochallenge and are being challenged by their own beliefsand values

Contemporary health care and existing dominantdiscourses of the body and soul are being challenged bythe rigors of science such as described by quantumphysics vibrational medicine (OrsquoBrien 2002 p164)energetic healing and various bodywork modalities Thereis a timeliness therefore about the need to considerflexibility in service provision recognise and attend tosome current rigidity of practice and thinking with in and between culturally diverse boundaries and parametersas offered by the likes of Wilding et al In this edition of AJAN papers explore a variety of boundaries systemsand beliefs related to the practice and service delivery of nurses

In our first paper Gardner et al outline researchconducted to inform the development of standards for nurse practitioner education in Australia and NewZealand Findings from this research include support formasterrsquos level education as preparation for the nursepractitioner and for programs with a strong clinicallearning component in-depth education for the sciencesof specialty practice and centrality of student directed andflexible learning models Next Cioffi using a qualitativedescriptive study provides a snapshot of the experiencesof culturally diverse family members who make thedecision to stay with their relatives in acute medical andsurgical wards Three main roles identified were carryingout in-hospital roles adhering to ward rules and facingconcerns Findings indicate nurses and family memberscould benefit from negotiating active partnerships and

FROM THE EDITOR ndash Dr Jackie Jones RN PhD

lsquoSOUL FOODrsquo IN AND OF NURSING ndash WHAT IS IT


EDITORIAL

that family friendly ward environments need to befostered supported by appropriate policies

Day and Batten having identified that cardiacrehabilitation programs have been based on research withalmost exclusively male participants investigate womenrsquosperceptions of the contribution of cardiac rehabilitation totheir recovery from a myocardial infarction UsingGlaserian grounded theory the core theme that emergedfrom their data was lsquoregaining everydaynessrsquo Theseauthors found programs did not meet the needs of allparticipants and it was apparent that one size does not fitall The final research paper from Brumley et al aimed toimprove access to clinical information for nurses anddoctors providing after hours community palliative care in a regional Australian setting They describe an actionresearch project designed to improve collation anddistribution of succinct pertinent and timely informationabout unstable palliative care patients to nurses andgeneral practitioners (GPs) involved in after hours care

Dewar reviews the nursing research literature onchronic pain in the older person living in the communityShe argues that to provide care the many parameters

of chronic pain which include physical as well as thepsycho-social impact and the effect of pain on patientsand their families must be carefully assessed Furtherthat the beliefs of the older person about pain and painmanagement are also important and not necessarilysought Our final scholarly paper by Clark et al draws onexperiences from a national clinical research study tohighlight the registration issues for nurses who wish topractice nationally particularly those practicing within thetelehealth sector The authors found that the state andterritory structure of the regulation of nursing in Australiais a barrier to the changing and evolving role of nurses in the 21st century and consider this a significant factorwhen considering workforce planning

REFERENCESAustralian Nursing and Midwifery Council 2006 National CompetencyStandards for the Registered Nurse (Standard 95) wwwanmcorgau

OrsquoBrien K 2002 Problems and potentials of complementary and alternativemedicine Internal Medicine Journal 32(4)163-164

Wilding C Muir-Cochrane E and May E 2006 Treading lightly spiritualityissues in mental health nursing International Journal of Mental HealthNursing 15(2)144-152


GUEST EDITORIAL

Increasing internationalisation of nursing highlightsthe need for an increasingly flexible nursingworkforce (Buchan and Sochalski 2004) The

International Council of Nurses advocates lsquoviable andappropriate systems of professional regulation bothnationally and internationallyrsquo in response to the increasedmobility of nursesrsquo (ICN 2005) A good place to start ismore flexible processes for cross border recognition ofnursing practice Today there are increasing opportunitiesfor cross border nursing practice including telenursingsupporting rural and remote communities agencynursing emergency response for example retrievalservices transplantation coordinators and emergencydisaster response

We are seeing more lsquonursing sans frontiersrsquo especiallyin response to significant world events including theSouth East Asian tsunami and Hurricane Katrina in theUnited States As Jill Iliffe states lsquoDisasters bring home tous the real importance of community and collectiveresponses When people work together they achievebetter outcomesrsquo (Iliffe 2005) St John Ambulanceoperates in 44 countries providing opportunities fornurses who are members to assist not only as acomponent of disaster response but also planned eventssuch as the Commonwealth Games Locally firstresponder organisations including St John may deploymembers including nurses to emergencies to assistneighboring states and territories in times of need

The increasing application of information technologyto nursing practice will open more opportunities fornational nursing practice This is happening now and is not some lsquo2020rsquo problem Electronic data-basescomputerised care plans tele-nursing4 online nursingeducation and video-conferencing were once futuristicconcepts of health care and are now very much lsquonormalrsquo practice

There is no more evident need for a singular process ofnursing registration to enable cross border practice thanwithin the states and territories of Australia There iscurrently no such thing as an Australian nurse or doctor or allied health worker There is of course a state basednurse ndash a Queensland RN or a Victorian RN The currentsituation in Australia is there are eight different regulatoryauthorities for nursing (Bryant 2001) Each state orterritory holds state legislation to guide and regulatenursing practice All states or territories requireregistration with the local nurse regulatory authority in the jurisdiction in which they are practicing Thissupports eight systems of variable levels of difficulty to gain registration

The Commonwealth of Australia does provide aMutual Recognition Act 1992 for goods and occupationswhereby registered nurses and midwives may apply formutual recognition of their nursing registration Thisprocess is of little value to St John nurses volunteering toa cross border incident such as a bushfire and may costfor multiple nursing registration fees up to a maximum of$900 per year

In this edition of the Australian Journal of AdvancedNursing the editor has published a timely case study byClark et al of a clinical nursing research teamimplementing a national program Clark et al have made acall for the nationalisation of nursing regulation in thiscountry (ANMC 2005) They have presented their caseafter an extraordinary three years experience in dealingwith state based bureaucratic regulatory inconsistencies

An Australian Nursing and Midwifery Council wasestablished to facilitate a national approach to nursing andmidwifery regulation Core activities include identifyingimpacting factors on nursing and midwifery regulationfacilitating relevant projects and fostering cooperation onnursing and midwifery regulatory matters The ANMC isnow represented on the ICN Observatory on Licensureand Regulation exploring global regulatory practicescalling for more flexible regulation (ANMC 2006) TheANMC released a position statement on cross bordernursing practice (Duffield et al 2002) Their statement onmutual recognition provides a means for fee waiver butstill supports eight different systems in relation toregistration in the different states The current system canonly respond to requests that are planned and is onlyavailable during business hours

The ICNrsquos current focus on disaster nursing willchallenge national nursing regulation systems Assuggested by Clark multiple state registrations is rarelypracticable St John has experienced similar difficultiesand have found it impossible to develop a nationalAustralian position on cross border deployment inemergency situations for their nursing volunteers Nursesface a system that is complex time consuming veryexpensive and not responsive to urgent requests

There are international conversations occurringregarding nursing workforce mobility (Clark et al 2006)The International Council of Nurses describes a need forviable responsive and appropriate regulatory systemsThere is a need to ascertain clarity on a national levelbefore embarking on global complexities The highlyflexible nursing workforce required to meet currentdemands requires mutual recognition across Australia

GUEST EDITORIAL ndash Dr Kathryn Zeitz RN PhD Chief Nursing Officer St John AmbulanceAustralia zeitzonaustraliacom

WORKING TOGETHER FOR BETTER OUTCOMES


GUEST EDITORIAL

Mutual recognition for cross border practice needs to be

more than a token waiver of fees A consistent and

automatic process for recognising registered nurses

practicing across borders needs to be either incorporated

into all local registration systems or a singular national

Act needs to be developed lsquoWhen people work together

they achieve better outcomesrsquo (Iliffe 2005)

REFERENCESBuchan J and Sochalski J 2004 The migration of nurses trends and policies

Bulletin of the World Health Organisation 82(8) Geneva

The International Council of Nurses 2005 Nursing Regulation a Futures

Perspective ICNWHO Position Statement wwwicnchps_icn_who_regulationpdf

Iliffe J 2005 Collective responses achieve better outcomes Australian NursingJournal 12(7)1

Western Australia Department of Health HealthDirect 2006wwwhealthwagovauservicesdetailcfmUnit_ID=799 (accessed 2006)

Bryant R 2001 The Regulation of nursing in Australia a comparative analysisJournal of Law and Medicine 9(1)41-57

Clark R Yallop J Wickett D Krum H Tonkin A and Stewart S (2006)Nursing sans frontiegraveres a three year case study of multi-state registration tosupport nursing practice using information technology Australian Journal ofAdvanced Nursing (for publication Issue x No x)

Australian Nursing and Midwifery Council 2005 A global look at nursing AnneMorrison talks about the international Observatory on licensure and regulationIssue 30 wwwanmcorgaudocsnewslettersnewsletter_June_2005_final2pdf

Australian Nursing and Midwifery Council 2006 Cross border Nursing Practice waiver of fees Policy Statement wwwanmcorgaudocsMay_06_Cross_Border_Nursing_Midwiferypdf

Duffield C and OrsquoBrien-Pallas L 2002 The nursing workforce in Canada andAustralia two sides of the same coin Australian Health Review 25(2)136-44

8Australian Journal of Advanced Nursing 2006 Volume 24 Number 1

RESEARCH PAPER

ABSTRACT

ObjectiveThe objective of this study was to conduct research

to inform the development of standards for nursepractitioner education in Australia and New Zealandand to contribute to the international debate on nursepractitioner practice

Setting The research was conducted in all states of

Australia where the nurse practitioner is authorisedand in New Zealand

SubjectsThe research was informed by multiple data sources

including nurse practitioner program curriculadocuments from all relevant universities in Australiaand New Zealand interviews with academic convenorsof these programs and interviews with nursepractitioners

Primary argumentFindings from this research include support for

masterrsquos level of education as preparation for thenurse practitioner These programs need to have astrong clinical learning component and in-deptheducation for the sciences of specialty practiceAdditionally an important aspect of education for thenurse practitioner is the centrality of student directedand flexible learning models This approach is wellsupported by the literature on capability

Conclusions There is agreement in the literature about the lack

of consistent standards in nurse practitioner practiceeducation and nomenclature The findings from thisresearch contribute to the international debate in thisarea and bring research informed standards to nursepractitioner education in Australia and New Zealand

Acknowledgements

This project was sponsored by the Australian

Nursing and Midwifery Council and the Nursing

Council New Zealand We also wish to acknowledge

the contribution of the nurse academics and the nurse

practitioner clinicians in Australia and New Zealand

who generously gave their time to participate in the

study We also acknowledge Professor Stewart Hase

Southern Cross University and his expert contribution

through personal communication and publications on

capability learning

INTRODUCTION

The nurse practitioner is a new and unique level of

health care provider in Australia and New Zealand

The title nurse practitioner is now legally

protected in New Zealand and in most Australian states

and there is mutual recognition of registration between the

two countries

While the mutual recognition of registration has been

in effect for several decades there has been no

standardisation of education practice competencies and

authorisation process relating to the nurse practitioner

within the different jurisdictions in Australia or between

Australia and New Zealand To address this anomaly

the Australian Nursing and Midwifery Council (ANMC)

and Nursing Council New Zealand formally committed to

collaborative development of the nurse practitioner role

under a Memorandum of Cooperation and jointly

commissioned a study to develop research based

standards for nurse practitioner practice competencies and

education The research reported here is the findings

from this study related to educational standards for the

nurse practitioner

Glenn Gardner RN PhD FRCNA Professor of Clinical NursingQueensland University of Technology Kelvin Grove and RoyalBrisbane and Womanrsquos Hospital Queensland Australia

gegardnerquteduau

Sandra Dunn RN PhD FRCNA Professor of Clinical NursingPractice Flinders University and Flinders Medical Centre South Australia

Jenny Carryer RN PhD FCNA(NZ) MNZM Professor ofNursing Massey University and Mid Central District HealthBoard New Zealand

Anne Gardner RN PhD MRCNA Associate Professor in Nursing Deakin University and Cabrini Health Victoria Australia

Accepted for publication November 2005

COMPETENCY AND CAPABILITY IMPERATIVE FOR NURSE PRACTITIONER EDUCATION

Key words nurse practitioner education competencies capability advanced practice nurse education


RESEARCH PAPER

9

BACKGROUNDHealth care reform is on the agenda of most developed

countries including the USA (Lancaster et al 2000) UK(Charlton and Andras 2005) Australia (Duckett 2002) andNew Zealand (Ministry of Health 2001) Also in thesecountries nurse practitioners are playing a vital role inreforming health care through improved access (OrsquoKeefeand Gardner 2003) cost effective care (Burl et al 1998)and quality of care and improved patient satisfaction(Gardner and Gardner 2005) Additionally studies havedemonstrated that the nurse practitioner enhances teamapproaches to health care delivery (Litaker et al 2003)

The nurse practitioner role first originated in NorthAmerica in the 1960s and in the UK in the 1980s Theimpetus for implementation was related to the prevailinginequitable distribution of health care often attributed to ashortage of doctors and in response to the need to reducejunior doctorsrsquo hours cost containment in health serviceprovision and the need to provide improved access tohealth care services (Horrocks et al 2002 Harris andRedshaw 1998)

The burgeoning of the nurse practitioner role in NorthAmerica and the UK in response to community needs hasbeen echoed in Australia and New Zealand over the pastdecade Nurse practitioners have been formally practicingin some jurisdictions in Australia since 1999 and in New Zealand since 2001

Despite and possibly related to the rapid adoption andongoing development of the nurse practitioner roleinternationally there is little research related toeducational standards for the nurse practitioner Thispaper reports on the educational aspect of the findingsfrom the ANMC Nurse Practitioner Standards Project(Gardner et al 2004a)

METHODThe overall aim of the study was to investigate nurse

practitioner education and practice in Australia and New Zealand and to draw upon this information incombination with relevant literature to develop corepractice competencies and educational standards thatcould be applied in both countries

The research design incorporated a multi-methodsapproach with a range of data collection tools and data sources including current policy documents nursepractitioner program curricula and interviews withacademics and clinicians Data were collected fromrelevant sources in Australia and New Zealand

Participant sample and recruitment processesA population sample of authorised and practising

nurse practitioners and the academic convenors from allnurse practitioner programs being offered in Australia and New Zealand during 2004 was used

Nurse practitioners in New Zealand and relevant statesin Australia were invited to participate in the studyThrough the nursing regulatory authority in eachjurisdiction nurse practitioners were contacted andinvited to respond to one of the investigators if they wereinterested in participating in an interview

Academic convenors of all nurse practitioner educationprograms were identified through expert networks inAustralia and New Zealand and searching universityschool of nursing websites Programs under developmentwere excluded The academics were contacted by one of the investigators supplied with an informationdocument and consent form and invited to participateTheir participation involved submission of their nursepractitioner curriculum document and participation in afollow-up structured telephone interview

Data collection

Nurse practitioner educationThe curricula documents on all nurse practitioner

education programs in Australia and New Zealand were collected by one of the investigators who was notinvolved in nurse practitioner education at the time of the research A data abstraction tool to standardise theinformation from these documents was developed andtested (table 1) In addition semi-structured interviewswith academic program convenors were conducted by this investigator

Nurse practitionersTelephone interviews were conducted with consenting

nurse practitioners in New Zealand and relevantjurisdictions in Australia The in-depth interviewscollected text data on the experiential dimensions of nursepractitioner work and their perceptions of requisitepreparation for the role

Data analysis

Nurse practitioner curriculaThe data from all program curricula documents were

collated and analysed for patterns in relation to programcharacteristics teaching and learning process and programcontent Data from nurse academic interviews werematched to these fields to strengthen and confirm orqualify the abstracted curricula data

Nurse practitioner interviewsThe data from nurse practitioner interviews were

analysed according to the standard for qualitative data An inductive process was used to order the data accordingto identified themes within each interview These themeswere then collated according to identified conceptualcategories A final read cross-checked all interviews forthe identified categories


RESEARCH PAPER

10

FINDINGSThis data collection was conducted in 2004 and the

findings reported here reflect the state of nurse practitionereducation in Australia and New Zealand at that time

Fourteen program curricula comprising five from New Zealand and nine from Australian universities wereincluded in the study This represents 100 per cent of nursepractitioner programs offered throughout the two countriesin 2004 Interviews were conducted with 12 academicconvenors While all universities sent their curriculadocuments for inclusion in the study convenors from two of these universities did not follow up requests toparticipate in interview

Data have been aggregated and reporting is in the formof trends and patterns The findings from analysis of nursepractitioner interviews are integrated in each of the areas

Program Characteristics

Level and duration of award Thirteen of the fourteen programs leading to the award

of a nurse practitioner qualification were masterrsquos degreesOf the masterrsquos degree programs six programs were foursemesters in length and seven were three semesters(equivalent full time) Academic convenors all agreed thatthe masterrsquos degree was an appropriate standard for nursepractitioner education

In interviews with nurse practitioners participants wereasked their view on the level of education necessary fornurse practitioner training Most suggested masterrsquos degreeand their reasoning related to

bull public perception of the level and stature of a masterrsquosdegree as an important aspect of ensuring publicconfidence in nurse practitioner service

bull a belief that the masterrsquos degree offers scholarship thatis comparable with the nature of the skills knowledgeand attributes required and

bull personal experience of the value of that level of education

In some instances nurse practitioners provided supportfor this view based on their own experiences as pioneerswhile others offered a perspective influenced by havingcome to the nurse practitioner role through a differentroute Nurse practitioners who did not have a masterrsquosdegree tended to take a more qualified stance and wereoverwhelmingly committed to the primacy of clinicalexperience as preparation for the nurse practitioner role

Entry requirementsEntry requirements across the 14 programs were

highly consistent with the main variation being inrequirements for experience in the specialty This variedfrom none to five years Nine of the programs requiredpostgraduate trainingqualifications in the specialty fieldand most of these were integrated into the masterrsquos degree

Ethical approval for the study was secured fromrelevant university Human Research Ethics CommitteesInformed consent was obtained from all participantsSpecific assurances were given to universities andobserved by the research team regarding commercial-in-confidence issues

Table 1 Data Abstraction Tool ndash Nurse Practitioner Curricula

1 Program Characteristics

11 Name of University

12 Title of program

13 Entry requirements

14 Level of award

15 Entry and exit points (if multiple)

16 Duration of Program FT semesters

17 Generalist or specialist NP programYesNo If yes list specialities offered

2 Program Management

21 Nurse Reg Authority accredited YesNo

22 Membership categories for curriculum committee

23 Membership categories for program advisory committeeStandards included YesNo

3 Conceptual Curriculum

31 Explicit assumptions informing content

32 Explicit assumptions informing process

33 Graduate profile

4 Program delivery

41 Study mode offered

42 Credentials of program convenor

43 Description of people involved in delivery

44 Teaching learning process

5 Program evaluation

List processes to be adopted for ongoing monitoring of the course

6 Program content

61 Aims and objectives

62 Employment requirements for entry to course

63 Clinical field learning Requirements

64 List course titles with brief description Link to competencies if explicit

7 Student assessment

71 List clinical assessment strategies (link to courses)

72 List non field based assessment strategies (link to courses)

73 Is assessment explicitly linked to competencies If yes list competencies

Note Program Refers to the total education experience leading to the qualificationalso called a lsquocoursersquo in some universities Course is an individual unit of studySeveral courses make up a program also called a lsquosubjectrsquo lsquounitrsquo or lsquopaperrsquo insome universities


RESEARCH PAPER

11

In terms of miscellaneous requirements two required acompleted portfolio for entry to the program and tworequired membership of professional specialty associationTen of the 14 programs had flexible entry and exit features

Scope of the programsThree of the programs were focused on one specific

specialty and six offered a range of structured specialtystudies Five universities offered programs with genericsubjects and a framework or assessment mechanisms toobtain advancedextended education in the candidatesrsquoown specialty In interviews with academics this lattermodel was described as a necessary approach to nursepractitioner education to facilitate the development of skillsand knowledge in new fields of extended nursing practice

Approaches to teaching and learningIn forming the basis for the education process certain

assumptions were common across all curricula Theserelated to the importance of

bull adult learning principles

bull learning as collaborative

bull use of the clinical field with clinical mentorpreceptor

bull use of experientialsituated learning and

bull promoting self-directedlifelong learning skills

Additionally all academics interviewed were committedto the clinical environment as a context for nursepractitioner education

Data from the nurse practitioner interviews alsostrongly supported the centrality of clinical learning aspreparation for the nurse practitioner role For some therewas a dichotomy Clinical experience was viewed asdifferent from and better than the (perceived) alternativeacademic orientation of a masterrsquos degree

Others were wary of the quality of the clinical contentin masterrsquos degree programs Participants in bothcountries who were very recent graduates of an approvedmasterrsquos degree expressed concern at the adequacy of the clinical content They were especially concerned for students who would come to the degree without the level of clinical experience which had informed their own student experience Consequently these nursepractitioners were adamant that the clinical rigour of themasterrsquos degree must be developed and maintained whilenot losing the special qualities of masterrsquos degree education

Curricula contentFindings from this study indicate that the prevailing

professional and regulatory environment in Australia in which nurse practitioner programs of education were designed was diverse with scant attention to national priorities and cross-border collaboration Thesituation in New Zealand is more cohesive due largely to the centralised nature of nursing regulation

The trans-Tasman context therefore is also diverse Hencethe content imperatives for nurse practitioner educationhave been determined locally and in response to localregulatory requirements and the attitudes and opinions ofeach health service or clinical environment

Accordingly one of the questions in the interviewswith academics related to the factors that influenced theprogram content The responses were varied In oneprogram the content was designed from empiricalcurriculum research conducted during the nursepractitioner trial in their jurisdiction For the remaindercontent was determined through consultation with clinicalspecialists specialty competencies when availableadvisory committees medical practitioners and theacademicsrsquo own vision for the nurse practitioner roleAdditionally many were influenced by publications fromNorth America and the United Kingdom

In many of the programs the nurse practitioner streamwas embedded in a general nursing masterrsquos degreeHence it was at times difficult to determine thecontentcourses that were specifically designed for nursepractitioner education

Twelve of the programs required or preferred thecandidates to be currently employed in their specialtyfield The same pattern applied to the requirements forclinical subjects and internships where practice learningwas supported by a clinical team clinical preceptor ormentor For many of these courses the clinical learningsupport was provided by medical practitioners and otherhealth-care professionals

Across all programs there was a pattern relating to thespecific nurse practitioner content These data have beencategorised into three areas namely universal contentfrequent content and specialty content

Universal contentThree study areas were contained in all 14 programs

These were

bull Pharmacology In many programs the study ofpharmacology and pharmacotherapeutics wasiterative in that this content was spread in severalcourses across the curriculum

bull Research with or without a focus on evidence-basedpractice Research training while present in allprograms varied in terms of scope Some requiredcandidates to conduct a small research project orpractice audit while other programs containedresearch andor evidence-based practice courseswithout empirical study requirements

bull Assessment and diagnosis including imaging andlaboratory diagnostics This area of study was amajor feature in all programs While course titlesvaried there was a consistent commitment to contentrelated to advanced and extended assessment anddiagnostic skills


RESEARCH PAPER

12

Frequent contentOther study areas that were common across many of

the programs included

bull Clinical sciences (anatomy and physiologypathophysiology)

bull Nursing professional and scope of practice studies

bull Clinical leadership

bull Society law and ethics and

bull Studies in cultural awareness and cultural aspects ofnurse practitioner practice

Content such as symptom management and therapeuticswas listed in some programs however these areas of studytended to be linked to specialty streams

Specialty contentSpecialty content was apparent in two forms those

programs that had designated specialty focus or streams(n=9) and those programs with a generalist corecomponent and framework for specialty study (n=5) Thepattern of specialty education varied In some content inthe specialty streams focused on specialist assessment andtherapeutics that in some cases were guided by thecompetencies for that specialty Other programs locatedspecialty education in the clinical practicum componentThe remainder required the candidate to enter with a graduate diploma in a specialty field Those programswith frameworks for specialty study worked from learningcontracts andor clinical practicum with dedicatedpreceptorsmentors or a clinical team for specialty learning

Interviews with nurse practitioners included questionsrelated to content areas for nurse practitioner educationAdvanced assessment and pharmacology received toprating which was consistent with the curricula dataContent related to pathophysiology and health systemswith policy and political issues also receiving frequentmention Legal issues and research skills and utilisationwere noted as important

Analysis of nurse practitioner narratives ndash other issues The participants spoke strongly of what is described as

lifelong learning captured in the comment of oneparticipant lsquoas you go along you learn what you need toknowrsquo Several spoke of the difficulty in valuing oneparticular style of learning over another describing alleducation as valuable and some noting that theirappreciation for education expanded as their sense of therole developed All participants in different ways spoke ofthe necessary complexity of educational preparationThey emphasised the requirement for specific clinicalknowledge and skills and also the requirement forlearning how to learn and developing confidence in theirability to practice in an unpredictable and dynamicclinical professional and political context Consistentlythe data spoke to the need for a nursing model as the core tenet in preparation for nurse practitioner practice

The political vulnerability of these nurses in manysettings validates their need for a range of skills to ensuretheir professional safety

DISCUSSION

Preparation for practiceAnalysis of the nurse practitioner interview data

supports masterrsquos degree level of education as preparationfor the role This was justified on two levels First thefindings supported the need for strong educationalpreparation in order to meet the demands of the role The second level was related to credibility with thecommunity and other health disciplines as to thepreparedness of these clinicians best achieved by amasterrsquos degree for entry to practice These findings aresupported by the international literature where there is astrong trend to recommending masterrsquos degree programsfor advanced practice and therefore nurse practitionereducation (Fowkes et al 1994 American Academy of Nurse Practitioners 1995 Davidson 1996 de Leon-Demare at al 1999 Aktkins and Ersser 2000 van Soerenet al 2000)

Specialisation is an important issue in nurse practitionereducation and analysis of the curricula data identified two approaches used to deliver specialty studies Theseapproaches included a) structured specialty streams orprograms and b) generic frameworks that couldaccommodate a studentrsquos chosen specialty field of studyWhile some of the specialty streams and programs wereinformed by specialty competencies (eg Council ofRemote Area Nurses of Australia Inc 2001) others reliedon generic advanced practice competencies

The findings also support the need for a significantclinical learning component in nurse practitionereducation Nurse practitioner participants universallyendorsed the centrality of the clinical environment tonurse practitioner education There was also universalsupport from the academics interviewed for clinicallearning to be a major component of the programs A related issue on nurse practitioner education that wasstrongly supported by both clinicians and academics was the importance of student-directed learning Thesefindings are supported by research (Gardner et al 2004b)which reported the critical role played by the clinicalenvironment in nurse practitioner training and thepreference of nurse practitioner candidate participants forstudent-determined learning content and process

In looking to educational theory that met the jointimperatives of student directed learning and contextuallearning the literature on capability (Hase and Davis1999 Stephenson and Weil 1992) provided an importanttheoretical framework to inform curriculum developmentfor nurse practitioner education A capability approach to the learning process incorporates the flexibility torespond to the specific self-identified learning needs ofstudents (Phelps at al 2001)


RESEARCH PAPER

13

Capable practitioners are those who know how tolearn are creative have a high degree of self efficacy canapply competencies in novel and familiar situations andwork well with others (Hase and Davis 1999) Furthermorecapability emphasises the role of complexity in influencingthe learning context whereby dynamic systems providethe environment for non-linear and unpredictable events(Hase 2000 Phelps et al 2001) The clinical environmentof health care therefore is a fitting milieu for the basis ofnurse practitioner education and student-identified needsas an appropriate learning process

Lack of standardisationApart from these areas of agreement the findings

relating to nurse practitioner education indicate that a variety of standards competency frameworks andinterpretations of the role of the nurse practitioner have informed curricula development and accreditationapproaches There is also variability in educational levelsfor nurse practitioner education and a lack of consistencyin the conceptual basis of these programs Content variesacross the programs with just three study areas ofpharmacology research and advanced assessment beingcommon to all One of the particularly inconsistentfactors in the nurse practitioner education programsacross the Australian states and between Australia andNew Zealand is the lack of clarity in terms of specificnurse practitioner as distinct from advanced practicestudy requirements This is consistent with the literatureon nurse practitioner education (Woods 1999) where thereis confusion and ambiguity related to nomenclature andeducational requirements for the nurse practitioner(Gardner et al 2004b)

Recommendations toward national trans-Tasmanstandards for NP education

The findings from this research contribute to theinternational debate and also present an opportunity for Australia and New Zealand to take a global leadershiprole in adopting a standardised research-informed approachto nurse practitioner education and nomenclature Theadvantages for the Australian interstate and trans-Tasmancontext are significant

This research has identified the need for a two-layeredstructure for nurse practitioner education This includes i)the ANMC nurse practitioner competency framework thatinherently describes the knowledge attitudes and skills ofextended practice (Gardner et al 2005) and ii) the conceptof capability which defines the features of performanceof these competencies that are in combination uniquelyrelated to the method of nurse practitioner practice

Nurse practitioner education programs that arestructured to meet these generic standards will need to address not only the content requirements of acompetency framework but most importantly the learningprocess and assessment requirements as determined bythe imperatives of capability theory (Gardner et al 2004aStephenson and Weil 1992) This two layered approach isillustrated in figure 1 As Hase and Davis (1999) suggestbecoming capable requires different learning experiencesfrom becoming competent This thinking is also relevantfor the specialty learning required in the extendedpractice context Nurse practitioner candidates asadvanced specialist nurses are well placed to define andrespond to their own specific learning needs Structuredpedagogical approaches to learning will be inadequate forthe education of the nurse practitioner

Figure 1 Model for NP education

1 Competency frameworkDynamic practiceClinical knowledge and skillsComplex environmentsCurrency of knowledge

Professional efficacyNursing model of practiceSocial and cultural partnershipsAutonomy and accountability

Clinical leadershipInfluence at systems level of health careLeads in collaborative practice

4 Capability informed assessmentAssessment is oriented toward application of specialist cmpetencies in complex and unstructured situationsAssessment is formative and scenario basedAssessment includes stratgies that require candidates to gather together evidence of experience learning andpractice to demonstrate capability in practice and learning potential

2 Specialty indicatorsDynamic practiceSpecialist knowledge of science and the evidence base for therapeutic interventionsin the range of specialty contexts of practice

Professional efficacySpecialty practice intersect with generic requirements for nursing values andimperatives and the social and cultural environments of the specialty that aresustained and enhanced through autonomy and accountability

Clinical leadershipLeadership in the specialty field focuses on influencing systems level decisions toenhance health service for the community relevant to the specialty field of practice(eg rurl community mental helth service renal services etc)

3 Capability learningLearning strategies include learning contracts problem-based learning situated learning experiential learning clinical learning environment flexible andrepsonsive learning pathways as well as traditional approaches to supporting skills acquisition

NURSE PRACTITIONER EDUCATIONAL STANDARDS


Capability learning offers an alternative in the form offlexible learning pathways that allow for increasingcomplexity and curriculum scaffolding through a richvariety of learning resources and mentored self-directedlearning (Phelps et al 2001)

The model in figure 1 illustrates the configuration ofall elements related to nurse practitioner education andthe interface between the requirements for competencylearning and assessment and the influences of capabilitytheory on the learning environment for nurse practitionereducation The structure illustrates standards to supporttertiary education providers in the development anddelivery of nurse practitioner masterrsquos degree programsAdditionally the model provides an evidence informedbenchmark that can be applied in the accreditation ofcourses leading to authorisation as a nurse practitioneracross all regulatory jurisdictions in Australia and New Zealand

REFERENCESAtkins S and Ersser S 2000 Education for Advanced nursing practice anevolving framework International Journal of Nursing Studies 37(6)523-533

American Academy of Nurse Practitioners 1995 Position statement on nursepractitioner curriculum wwwaanporgPublicationsAANP+Position+StatementsPosition+Statements+and+Papersasp

Burl JB Bonner A Rao M and Khan A 1998 Geriatric Nurse Practitionersin Long Term Care demonstration of effectiveness in managed care Journal ofthe American Geriatrics Society 46(4)506-510

Charlton B G and Andras P 2005 Modernising UK health services lsquoshort-sharp-shockrsquo reform the NHS subsistence economy and the spectre of healthcare famine Journal of Evaluation in Clinical Practice 11(2)111-119

Council of Remote Area Nurses of Australia 2001 National Remote AreaNurse Competencies Armidale The Centre for Research in Aboriginal andMulticultural Studies (CRAMS)

Davidson C 1996 The need for a standardized core curriculum NursePractitioner 21(4)155-156

de Leon-Demare K Chalmers K and Askin D 1999 Advanced practicenursing in Canada has the time really come Nursing Standard 14(7)49-54

Duckett SJ 2002 The 2003 - 2008 Australian Health Care Agreements anopportunity for reform Australian Health Review 25(6)24-26

Fowkes K Gamel N Wilson S and Garcia R 1994 Effectiveness ofeducational strategies preparing physicians assistants nurse practitioners and

certified nurse-midwives for under serviced areas Public Health Report109(5)673-682

Gardner A and Gardner G 2005 A trial of nurse practitioner scope ofpractice Journal of Advanced Nursing 49(2)135-145

Gardner G Carryer J Dunn S and Gardner A 2004a Nurse PractitionerStandards Project Report to the Australian Nursing amp Midwifery CouncilDickson ACT ANMC

Gardner G Carryer J Gardner A and Dunn S 2005 Nurse Practitionercompetency standards findings from collaborative Australian and New Zealandresearch International Journal of Nursing Studies 43(5)601-610

Gardner G Gardner A and Proctor M 2004b Nurse Practitioner education acurriculum structure from Australian research Journal of Advanced Nursing47(2)143-152

Harris A and Redshaw M 1998 Professional issues facing nurse practitionersand nursing British Journal of Nursing 7(22)1381-1385

Hase S and Davis L 1999 From competence to capability the implicationsfor human resource development and management Paper read at Association ofInternational Management 17th Annual Conference San Diego

Hase S 2000 Measuring organisational capacity beyond competence Paperread at Future Research Research Futures The 3rd Australian VET ResearchAssociation Conference Canberra

Horrocks S Anderson E and Salisbury C 2002 Systematic review ofwhether nurse practitioners working in primary care can provide equivalent careto doctors British Medical Journal 324(7341)819-823

Lancaster J Lancaster W and Onega LL 2000 New Directions in HealthCare Reform Journal of Business Research 48(3)207-212

Litaker D Mion LC Planavasky L Kippes C Mehta N and Frolkis J2003 Physician - nurse practitioner teams in chronic disease management theimpact on costs clinical effectiveness and patientsrsquo perception of care Journalof Interprofessional Care 17(3)223-237

New Zealand Ministry of Health 2001 The Primary Health care StrategyWellington Ministry of Health NZ

OrsquoKeefe E and Gardner G 2003 Researching the sexual health nursepractitioner scope of practice a blueprint for autonomy Australian Journal ofAdvanced Nursing 21(2)33-41

Phelps R Ellis A and Hase S 2001 The role of metacognitive and reflectivelearning processes in developing capable computer users Paper read atMeeting at the Crossroads18th Annual Conference of the Australian Societyfor Computers in Learning in Tertiary Education Melbourne

Stephenson J and Weil S 1992 Quality in learning A capability approach inhigher education London Kogan Page

van Soeren M Andrusyszyn M Laschinger HS Goldenberg D and DiCensoA 2000 Consortium approach for nurse practitioner education Journal ofAdvanced Nursing 32(4)825-833

Woods LP 1999 The contingent nature of advanced nursing practice Journalof Advanced Nursing 30(1)121-128

RESEARCH PAPER

14

Jane Cioffi RN BAppSc(Adv Nsg) Grad Dip Ed (Nsg)MAppSc(Nsg) PhD FRCNA Senior Lecturer School ofNursing University of Western Sydney Australia

jcioffiuwseduau



RESEARCH PAPER

ABSTRACT

Objective To describe the experiences of culturally diverse

family members who make the decision to stay withtheir relatives in acute care wards

Design A qualitative descriptive study

Setting Medical and surgical wards in an acute care

hospital with a 70 non-English speaking backgroundpatient population

Subjects Eight culturally diverse family members who stayed

with their hospitalised relatives for at least four shiftsor the equivalent hours

Method In-depth interviews of approximately 45 minutes

Findings Three main categories described the experience

of family members These categories were carrying out in-hospital roles adhering to ward rules andfacing concerns

Conclusions Findings indicate nurses and family members could

benefit from negotiating active partnerships familyfriendly ward environments need to be fosteredsupported by appropriate policies and further researchis needed into culturally diverse family membersrsquopartnerships with nurses in acute care settings

INTRODUCTION

Australia is a multicultural country (Roach 1997)with culturally diverse people encompassingpeople of Indigenous and migrant backgrounds

(Roach 1999) When culturally diverse patients arehospitalised they often have a preference for their familymember to stay with them This preference results innurses managing family member access during theirrelativersquos stay in hospital However little is known aboutthe experiences of these culturally diverse familymembers This study describes the experiences of familymembers who have stayed with their relatives during theirhospitalisation

In many cultures illness is a family affair and familymembers play an important role in care-giving (Changand Harden 2002) Family members have a right tosupport their hospitalised relatives (Johnson 1988)According to Chang and Harden (2002) nurses and otherhealth care providers need to be willing to share the act ofcaring with family members so hospitalisation does notinterfere with for example family responsibility andcustoms When culturally diverse patients are admitted toacute care settings their families need to feel comfortablewith the access to their relative that is available to them

Family members involved in caring for hospitalisedadults have been shown to exhibit vigilance (Carr andFogarty 1999) Studies found two main forms of care areprovided by family members em otional support (Li et al2000 Astedt-Kurki et al 1997 Laitinen 1994 1993 1992Halm and Titler 1990) and visiting and helping withactivities of daily living or procedures (Li et al 2000Astedt-Kurki et al 1997 Laitinen 1994 1993 1992Collier and Schirm 1992 Haggmark 1990 Halm andTitler 1990 Sharp 1990) Family involvement has beenstudied with two main groups of adult patients thehospitalised elderly (Li et al 2000 Higgins and Cadd1999 Greenwood 1998 Collier and Schrim 1992) and the patient in critical care (Soderstrom et al 2003Walters 1995 Halm and Titler 1990) No studies werefound that focused on culturally diverse patients in acutecare settings

CULTURALY DIVERSE FAMILY MEMBERS AND THEIR HOSPITALISEDRELATIVES IN ACUTE CARE WARDS A QUALITATIVE STUDY

Key words family members experiences hospitalisation culturally diverse


Studies have examined the needs and involvement offamily members in the care of their hospitalised elderlyrelatives in acute care settings (Li 2005 Li et al 2000Higgins and Cadd 1999 Greenwood 1998 Collier andSchrim 1992) In general the needs of family membershave been found to be for information emotional supporthope a caring attitude and to be close to their relative(Rutledge et al 2000) Further aspects of family memberdissatisfaction that have been identified include a lack ofrespect for themselves and their hospitalised relative alack of information and inadequate care (Von Eigum2000 Athlin et al 1993) However little attention hasbeen given to the culturally diverse family member whowishes to be involved in the care of their hospitalisedrelative despite nurses regarding the relationship betweenpatients and their family as core to nursing care (Suhonenet al 2002 Astedt-Kurki et al 2001) This study exploredthe experiences of culturally diverse family members whomade the decision to stay with their relatives in acute carewards during their relativesrsquo hospitalisation

METHOD

Research approachThis qualitative study describes experiences of

culturally diverse family members staying with theirhospitalised relatives on medical and surgical wards in an acute care hospital with a 70 non-English speakingbackground patient population An interpretive-descriptive design in the qualitative tradition (Thorne et al1997) has been selected to address the question as it cancapture the multiplicity of family member experiences inacute care hospital wards

SamplingEight family members who volunteered to join the

study and met the inclusion criteria formed the purposivesample The criteria for recruitment of a family memberto the study were had stayed with their hospitalisedrelative for at least four shifts or the equivalent hours andwere culturally diverse The resultant sample of culturaldiverse family members had lived in Australia for morethan 10 years with seven having previous experience ofhospitals (see table 1) Their hospitalised relatives werepublic patients in hospital from three to eight days withfive being hospitalised for a surgical procedure and threefor a medical condition

Study sampling was based on the estimation of Kuzel(1992) that six to eight family members are required for a sample that is homogeneous with regard to a commonexperience This experience was staying with ahospitalised relative on an acute care ward Ethicsapproval was obtained from both the area health serviceand university human research ethics committees Allappropriate ethical aspects of the study were addressed toensure the rights of participants were protected

Data collection procedureEach participant interview was scheduled at a time and

place convenient to them Interviews were approximately45 minutes in duration and were audiotaped Allinterviews were carried out by the investigator andcommenced with the open-ended question lsquoCan you tellme about your experience of staying with yourhospitalised relative on the wardrsquo Participants wereencouraged to talk freely about their experiences andfeelings and asked to clarify extend or explain further ifable particular aspects of relevance to answering theresearch question When the participant indicated theyhad no more to share pertinent to the question theinterview was concluded Each participant was asked ifthey were willing to be contacted when the findings of thestudy were available to consider their credibility in lightof their experiences Contact details of three participantswere obtained

Data preparation and analysisTranscribed tapes were checked for accuracy then

all transcriptions were read until a full understanding of their meaning was grasped (Thorne et al 1997)

RESEARCH PAPER

16

Table 1 Characteristics of family members

Characteristic f=

Ethnicity - Lebanese 4- Tongan 2- Turkish 1- Vietnamese 1

Gender- Male 1- Female 7

Relationship- Spouse 4- Daughter 3- Son 1

Age Range (in years)21-40 241-60 461-80 2

Table 2 Main categories and subcategories that described familymembersrsquo experiences

Category Sub categories

Carrying out in-hospital roles - being with their relative- helping the nurses- acting as an interpeter- being the family representative

Adhering to the ward rules - going with the rules- recognising access as a privilege- tension around rules

Facing concerns - person-centred- relative-centred


Data were analysed using Lincoln and Guba (1985)approach with units of meaning being identified thengrouped into categories and subcategories based onsimilarity Following this the resultant findings werepresented to the three participants who had indicated adesire at the interview to be involved in the verificationprocess These participants considered their experienceswere captured by the categories and subcategoriesBilingual health care workers who liaised with non-English speaking patients their families and nursing staffon a daily basis were also shown the findings andindicated they reflected their experiences of working withculturally diverse family members

FINDINGSThe family members described their experience of

staying with their hospitalised relative within three maincategories These categories are carrying out in-hospitalroles adhering to the ward rules and facing concernsThe categories and subcategories are presented in table 2followed by each category and its subcategories beingdescribed in detail

Carrying out in-hospital rolesIn-hospital roles identified were being with their

relative helping the nurse acting as an interpreter andbeing the family representative The role of being withtheir relative involved staying with their relative forvarious lengths of time From family member descriptionsthis was in the form of a presence and occurred during theday and into the evening most usually Below are examplesof the nature of this presence for family members

lsquoItrsquos sort of like a duty for us to come and look afterher itrsquos in the blood of us Especially when we are sick in my heart I have to be here for her lsquo

lsquoIn our culture when our loved ones come intohospitalhellip we include ourselves in the situation Irsquom herefor him for everything he wantsrsquo

Another role family members assumed when stayingwith their relatives was helping the nurses For mostfamily members this involved caring for their relativewhen at the bedside A typical description is

lsquoSort of helping giving a hand to the nurses helpingdaily living plan things like that Itrsquos our culture workall together rsquo

As culturally diverse hospitalised relatives oftenexperienced difficulties with language family membersidentified they were required to act as an interpreter fortheir relatives for example

lsquo he likes to have someone here to translate for himSometimes he has a question to ask and his English isnrsquot good so he feels that he hasnrsquot fully explained it to the doctor and that the doctor is not picking up on everything that he wants him to know Thatrsquos when hegets concernedrsquo

lsquoMy mum wouldnrsquot like the hellip interpreter Itrsquos easier for her if one of her children is here When we are hereshe can just tell us everything and we can tell the doctorsand nursesrsquo

All the family members disclosed their familiesexpected them to be the family representative A typicalcomment by a family member was

lsquoThe family depends on me all of them Whatever I willsay they will say yes I have to tell the family whatrsquos goingon with our dadrsquo

Adhering to the ward rulesFamily members showed they were extremely aware of

the ward rules that arose from hospital policy Theyshowed they considered them when making decisions tobe with their relatives The need to go by the rules torecognise access as a privilege and tensions associatedwith this situation were described by all family membersTypical descriptions of going by the rules are as follows

lsquoThe hospital has its own rules have to go with themrsquo

lsquo in my heart I know I want to sleep here with her butI have to go with their rulesrsquo

They recognised access as a privilege that wasextended to them most usually by nurses The descriptionbelow is an example

lsquoUsually I come every morning and stay up to eighthours They allow me in just to look after him I donrsquotthink that Irsquom in a position to ask for any more than thatrsquo

Some tension around access that created discomfortfor family members was described These tensions wereassociated with obtaining permission and their actualpresence at the bedside The extracts below show that theywere careful not to upset the access privileges they hadbeen given Examples are

lsquoWhen Mumrsquos resting I try to sneak out for a cup of teabut itrsquos mainly just to get out of the way Irsquom just veryhappy that they allow me to be here with her outside thevisiting hoursrsquo

lsquoI never annoy them I come here and give him hislunch then go downstairs I come back at two I didnrsquotwant them to see too much of me because some of themmight say ldquoWhy is she hererdquo I never disturb themrsquo

Facing concerns Concerns family members had to face when they

stayed with their relatives on the ward were both person-and relative-centred Each family member expressedperson-centred concerns about their experience of beingwith their relative that were varied and includerecognising they were not able to manage some aspects of their relativersquos care being uncomfortable aboutsituations they witnessed finding the strength to continue to support their relative and being worried

RESEARCH PAPER

17


Examples of personal concerns were

lsquoMy Vietnamese isnrsquot as good as my English so I find ithard to translate for my dad some of the stuffrsquo

lsquoThe nurses are short staffed and too busy to take care they are trying their best If I push them too much someof them are very very short-tempered They are not patientrsquo

lsquoIn my heart I just say things to God He gives me theenergy to come to the hospital and still have more energyto help comfort him and keep him company during the daybefore I go home and have a rest in time for the next dayrsquo

Family members were strongly aware of relative-centred concerns associated with being hospitalisedExpressed concerns involved their relativesrsquo preferencesbeliefs and emotional responses Concerns focused onpreferences included visiting and gender of attendants for example

lsquoShe finds it really hard as her visitors come in largenumbers about ten or more at once She knows how it ishere and that makes her uncomfortable In her heart shewishes that they come and go quicklyrsquo

lsquoAs he is Tongan letting a male nurse wash a male isreally a bit hard He prefers a woman So he just tells themale person who showers the men my wife will shower mersquo

The beliefs that hospitalised relatives held for exampleabout sickness were endorsed by the family members andin some cases influenced the interactions of familymembers with their relatives in the ward situation asdemonstrated in example extracts below

lsquoHe believes this illness is from God and God givesyou the illness to clean up many things in a person Hereally fears God so he is happy the sickness comes and hedoubles his thanks to God with prayer I help him to go tothe end room to prayrsquo

lsquoIn the Tongan way if no one is around him he will feellost Hersquoll feel Irsquom lost theyrsquove forgotten me he wonrsquot sayit to me but I know the feeling because wersquore born withthat feeling So I need to be here for himrsquo

The emotional responses of relatives were often ofconcern to family members Typical comments fromfamily members were

lsquoHe gets upset that some of the nurses donrsquot try harderto listen and understand him Their tone of voice the waythey looked down when he canrsquot explain what he wants tosay sometimes He gets a bit upset about thatrsquo

lsquoMy mum is one of those who is really really scaredwhen she is sick Thatrsquos why it is important we are here for herrsquo

The ward experience of a family member being withtheir hospitalised relative as described shows familymembers assume a series of roles that are supportive payattention to the rules of the ward andor hospital andexperience a number of concerns that are generated both from their relationship with their relative and the in-hospital situation

DISCUSSIONThe main findings that describe family membersrsquo

experiences in-hospital provide insight into their bedsideexperiences including their involvement with theirhospitalised relatives In many instances this involvementepitomised vigilance as identified by Carr and Fogarty(1999 p433) who described it to be a lsquoclose protectiveinvolvement with a hospitalised relativersquo Previous studieshave shown positive outcomes for hospitalised relativescan be affected with such involvement (Hendrickson1987 Simpson and Shaver 1990 Suhonen et al 2002)Further the individualisation of patient care can befostered (Suhonen et al 2002) This strongly indicates thatfamily members at the bedside are very beneficial andnurses need to include family members when planningand implementing care for patients With culturallydiverse families this may well be more criticalconsidering possible language and cultural difference

Nurses are mainly responsible for managing the accessof visitors to patients in wards where family members arewith their relatives This places nurses in a position wherethey are able to grant exceptions to the hospital visitingpolicy for family members Whitis (1994) reported asimilar authority existed in a study of visiting policiesFamily members were very aware that access was aprivilege granted to them by nurses Violation of thisprivilege was an issue for them and they took care lsquoto gowith the rulesrsquo and not aggravate or draw attention to theirpresence by the strategies they adopted This indicatesthat culturally diverse family members were notcomfortable with their access conditions

There is an opportunity for nurses to negotiate anapproach to access that respects cultural ways associatedwith illness and family care giving as recognised byChang and Harden (2002) Further a patientrsquos right to thesupportive presence of their family as identified byJohnson (1988) and Suhonen et al (2002) suggests this ethical imperative needs to be uppermost in thedecision-making process

The family member role of helping the nurse bygiving care to their relatives confirms findings fromother studies with intensive care patients (Halm andTitler 1990) and elderly patients in acute care settings(Collier and Schirm 1992 Laitinen and Isola 1996Laitinen 1994 1993 1992) Family members in thisstudy were carrying out caring activities on a voluntarybasis and recognised there were elements of care givingthey were unable to give or unfamiliar with and requirednurses to provide This aspect was not found in anyprevious study reviewed Family members did notindicate they had negotiated their helping role withnurses As well as the previously identified need tonegotiate clearly defined access conditions nurses needto also determine with each family member how theywish to be involved in their relativersquos care For examplethe aspects of care family members feel comfortable toprovide and those they would like nurses to provide

RESEARCH PAPER

18


These details need to be documented to ensure all staffare familiar with the agreed plan of family memberinvolvement in care

The finding of the family member acting as aninterpreter in the hospital setting was a role not previouslyidentified in other studies and can be attributed to theculturally and linguistically diverse nature of the familymembers and their relatives The informal use of familymembers as interpreters is a concern and needs carefulconsideration particularly in light of the family memberwho identified he had difficult with translation Whenfamily members are acting as interpreters for patientsnurses and other health professionals need to acquaintthemselves with relevant policies and provide a formalmeans of using qualified interpreters by booking regularsessions during each patientrsquos episode of care

Some family members actually identified that nurseswere short staffed very busy and at times short-temperedAccording to McQueen (2000) when nurses have heavyworkloads as is often the case today with higher patientacuity and short lengths of stay they are prone toconveying their stress to others Family membersdescribed nurses reacting in ways that suggest nurseswere at times overwhelmed by work conditions asindicated by their responses in wards where theirhospitalised relatives were Interactions between familymembers and nurses have been found to be complicatedby ward conditions (Astedt-Kurki et al 2001) Nursesneed support to manage their work conditionsappropriately and to build caring partnerships with afamily focus

Within family membersrsquo descriptions of theirexperiences there was little reference to the personalsupport they had received from nurses whilst at thebedside This supports Greenwoodrsquos (1998) assertion thatfamily members do not receive the attention and time theyneed on general wards A finding by Hardicre (2003)provides insight into this situation as nurses indicatedthey felt inadequately prepared to address this aspect Notonly do nurses need to provide care for their patients theyalso need to pay attention to the emotional and otherneeds of family members particularly when providingsupport to their hospitalised relatives

This study is small and only involves family membersfrom a limited number of ethnic backgrounds The focuson family members of adult patients in acute care settingsrequires more in-depth understanding than has beencaptured in this study Difficulties with recruiting andinterviewing family members who were at the bedsideresulted from their in-hospital commitments to theirrelatives Interviewing family members after theirrelativersquos discharge may result in improved recruitmentand increased duration of each interview

IMPLICATIONS AND RECOMMENDATIONSAccommodating family members demands nurses

immediately meet the challenge to engage with them in active partnerships sharing common goals andunderstandings These partnerships need to be fostered ina family friendly environment where co-operation andequality are hallmarks of caring relationships To supportthis hospital policies need to be reviewed to increase theirfamily friendly focus including flexible visiting times thatfacilitate family involvement Further nurses need to beprepared through continuing education programs todevelop and sustain collaborative partnerships with familymembers with documentation of family involvement inclinical pathways care plans and daily reports Researchinto family membersrsquo involvement in the care of adultculturally diverse patients is required to explore forexample access conditions and joint partnershipsbetween nurses family members and their relativesincluding family members from other ethnic backgrounds

REFERENCESAstedt-Kurki P Paavilainen E Tammentie T and Paunonen- Ilmonen M2001 Interaction between family members and health care providers in acutecare settings in Finland Journal of Family Nursing 7(4)371-390

Astedt-Kurki P Paunonen M and Lehti K 1997 Family membersrsquoexperiences of their role in a hospital a pilot study Journal of AdvancedNursing 25(5)908-914

Athlin E Furaker C Jannson L and Norberg A 1993 Applications ofprimary nursing within a team setting in the hospice care of cancer patientsCancer Nursing 16(5)388-397

Carr JM and Fogarty JP 1999 Families at the bedside an ethnographic studyof vigilence Journal of Family Practitioner 48(6)433-438

Chang MK and Harden J T 2002 Meeting the challenge of the new millennium caring for culturally diverse patients Urologic Nursing22(6)372-377

Collier JAH and Schirm V 1992 Family-focused nursing care ofhospitalised elderly International Journal of Nursing Studies 29(1)49-57

Greenwood J 1998 Meeting the needs of patientsrsquo relatives ProfessionalNurse 14(3)156-158

Haggmark C 1990 Attitudes to increased involvement of relatives in care of cancer patients evaluation of an activation program Cancer Nursing13(1)39-47

Halm M and Titler MG 1990 Appropriateness of critical care visitationperceptions of patients families nurses and physicians Journal of NursingQuality Assurance 5(1)25-37

Hardicre J 2003 Nursesrsquo experiences of caring for the relatives of patients inICU Nursing Times 99(29)34-37

Hendrickson SL 1987 Intracranial pressure changes and family presenceJournal of Neuroscience Nursing 19(1)14-17

Higgins I and Cadd A 1999 The needs of relatives of the hospitalised elderlyand nursesrsquo perception Geriaction 17(2)18-22

Johnson PT 1988 Critical care visitation and ethical dilemma Critical CareNurse 8(6)72 75-78

Kuzel AJ 1992 Sampling in qualitative inquiry in BF Crabtree and WL Miller (eds) Doing qualitative research Newbury Park California Sage

Laitinen P 1994 Elderly patients and their informal caregiversrsquo perceptions ofcare given the study-control ward design Journal of Advanced Nursing20(1)71-76

Laitinen P 1993 Participation of caregivers in elderly-patient hospital careinformal caregiver approach Journal of Advanced Nursing 18(9)1480-1487

Laitinen P 1992 Participation of informal caregivers in the hospital care ofelderly patients and evaluations of the care given pilot study in three differenthospitals Journal of Advanced Nursing 17(10)1233-1237

RESEARCH PAPER

19


Laitinen P and Isola A1996 Promoting participation of informal caregivers inthe hospital care of the elderly patient informal caregiversrsquoperceptions Journalof Advanced Nursing 23(5)942-947

Li H 2005 Identifying family care process themes in caring for theirhospitalised elders Applied Nursing Research 18(2)97-101

Li H Stewart BJ Imle MA Archbold PG and Felver L 2000 Familiesand hospitalised elders A typology of family care actions Research in Nursingand Health 23(1)3-16

Lincoln Y and Guba E 1985 Naturalistic inquiry Beverly Hills Sage

McQueen A 2000 Nurse-patient relationships and partnership in hospital careJournal of Clinical Nursing 9(5)723-731

Roach N 1999 Australian multiculturalism for a new century towardsinclusiveness Commonwealth of Australia Canberra

Roach N 1997 Multicultural Australia the way forward An issues paperNational Multicultural Advisory Services Canberra

Rutledge DN Donaldson NE and Pravikoff DS 2000 Caring for familiesof patients in acute or chronic health settings Part 1 ndash Principles OnlineJournal of Clinical Innovations wwwcinahlcom

Sharp T 1990 Relativesrsquo involvement in caring for the elderly mentally illfollowing long term hospitalization Journal of Advanced Nursing 15(1)67-73

Simpson T and Shaver J 1990 Cardiovascular responses to family visits incoronary care unit patients Heart and Lung 19(4)344-351

Soderstrom I Benzein E and Saveman B 2003 Nursesrsquo experiences ofinteractions with family members in intensive care units Scandinavian Journalof Caring Sciences 17(2)185-192

Suhonen R Valimaki M and Leino-Kilpi H 2002 lsquoIndividualised carersquo fromPatientsrsquo nursesrsquo and relativesrsquo perspective a review of the literatureInternational Journal of Nursing Studies 39(6)645-654

Thorne S Kirkham SR and MacDonald-Emes J 1997 Focus on qualitativemethods Interpretive description a non-categorical qualitative alternative fordeveloping nursing knowledge Research in Nursing and Health 20(2)169-177

Vom Eigen KA 2000 A comparison of carepartner and patient experienceswith hospital care Families Systems and Health The Journal of CollaborativeFamily Health Care 18(2)191-203

Walters JA 1995 A hermeneutic study of experiences of relatives of criticallyill patients Journal of Advanced Nursing 22(5)998-1005

Whitis G 1994 Visiting hospitalised patients Journal of Advanced Nursing19(1)85-88

RESEARCH PAPER

20


ABSTRACT

Aim To investigate womenrsquos perceptions of the

contribution of cardiac rehabilitation to their recoveryfrom a myocardial infarction

Background and Purpose Cardiac rehabilitation programs have been based

on research with almost exclusively male participantsIt was unclear if cardiac rehabilitation programs meetthe needs of women

Method Ten women who had experienced one or more

myocardial infarctions were interviewed Data fromthese interviews were analysed using Glaseriangrounded theory

Findings The core category that emerged from the data was

lsquoregaining everydaynessrsquo Participants worked toregain their lsquoeverydaynessrsquo through a basic socialprocess of lsquoreframingrsquo Reframing involved coming toterms with what they had experienced and fitting itinto their lives Other categories related to symptomrecognition and recovery

Conclusion Cardiac rehabilitation programs contributed to

overall recovery from a myocardial infarction indifferent ways for each participant Althoughprograms provided information for participants theyfailed to provide the type of support needed toeffectively aid reframing and recovery Programs didnot meet the needs of all participants and it wasapparent that one size does not fit all

INTRODUCTION

According to the New Zealand Ministry of Health(MOH) coronary heart disease (CHD) is theleading cause of death for New Zealanders In

1999 CHD accounted for 254 of male and 211 offemale deaths (New Zealand Health Information Service2003) Not only is mortality from CHD a problem in NewZealand and internationally the burden of diseaseresulting from CHD is also high In 1996 New Zealandwomen lost 25526 years to premature mortality and4296 years to disability as a result of CHD (Tobias2001) Cardiac rehabilitation (CR) programs weredeveloped to lessen the burden of disease both for societyand for the individual sufferer However these programshave been based on research using mostly male participants

CR is a dynamic multidisciplinary intervention thatassists individuals who have survived a myocardialinfarction (MI) or other cardiac event to achieve the bestlevel of functioning possible (Higginson 2003 Mitchell etal 1999) The aims of CR are to help individuals to adjustto their illness limit or reverse the disease modify riskfactors for future cardiac illness improve return tooccupational and social functioning and reduce the riskof re-infarction or sudden death (Dinnes 1998 Higginson2003 Mitchell et al 1999 Petrie and Weinman 1997Wenger et al 1995)

Internationally CR has three recognised phases phaseone - the inpatient phase phase two - the outpatient phase(up to 12 weeks post event) and phase three - themaintenance phase (AHA 1998 NZGG 2002 Parks et al2000) CR generally provides participants with educationon topics including basic heart anatomy and physiologythe effects of heart disease the healing process riskfactor modification the resumption of physical andsexual activities psychosocial issues the management ofsymptoms investigations individual assessment andreferral to other health professionals if required (NHFA2004 NHFNZ 2000) In New Zealand CR is based on theWorld Health Organisation (WHO 1993) guidelines

Phase one CR is generally an automatic part of in-patient hospital care for all MI patients integratedwithin the acute treatment plan In New Zealand phasetwo CR programs are of four to ten weeks duration for

Wendy Day RN BN MA (Hons) Lecturer School of NursingUniversal College of Learning Palmerston North New Zealand

wdayucolacnz

Lesley Batten RN BA MA (Hons) Lecturer School of HealthSciences Massey University Palmerston North New Zealand

Accepted for publication January 2005

CARDIAC REHABILITATION FOR WOMENONE SIZE DOES NOT FIT ALL

RESEARCH PAPER

Key words women myocardial infarction cardiac rehabilitation New Zealand


one or two afternoons per week depending on the healthservice providing the program (NHFNZ 2000) Programsmay be based in hospital grounds or at community basedsites CR nurses are largely responsible for the initiationof phase one CR during hospitalisation and most patientsare also visited at home by the CR nurse after dischargeand encouraged to attend phase two

LITERATURE REVIEWCR has been shown to benefit patients with a wide

range of cardiac conditions including following an MIResearch findings demonstrate an increase in functionalcapacity (Adams et al 1999 Cannistra et al 1992 Lavieand Milani 1995 Lavie and Milani 2000) and a decreasein mortality (Naughton et al 2000) for both men andwomen after CR CR has been linked to decreased levelsof anxiety and depression improvement in general healthand self-esteem (Conn et al 1992) shorter hospital staysbetter emotional and spiritual recovery and greatercompliance with lifestyle recommendations aimed atreducing cardiac risk factors (Guzetta and Dossey 1992)

There is some debate about womenrsquos rates of referraland attendance at cardiac rehabilitation programs Studiesby Cochrane (1992) Ades et al (1992) Everson et al(1998) and Allen et al (2004) found that women may not be referred for CR as readily as men despite bothgroups having similar clinical profiles However otherresearch by Burns et al (1998) did not identify gender as a predictor of referral

Halm et al (1999) Everson et al (1998) and Wallwork(1996) suggest that womenrsquos attendance at phase two CRis generally lower than that of men Parks et al (2000)performed an audit of the phase two CR program atAuckland Hospital and found that women were less likelyto attend than men with 36 of eligible women attendingin comparison to 49 of men

Halm and Penque (1999) identified that womenexperience different cardiac symptoms and present in adifferent manner than men when having an acute cardiacevent It was therefore considered possible that womenalso cope with symptoms and illness in different waysWomen and men are known to have different roles andresponsibilities within society so womenrsquos needs inrelation to CR may be different to those identified fromresearch with male populations The aim of this study wasto gain understanding of womenrsquos perceptions of thecontribution of CR to their recovery from an MI

METHODGrounded theory as informed by Glaser (1978) was

used as the methodology Prior to commencing this studyethical approval was obtained from the relevant regionalhealth and university ethics committees

SampleEligible participants were women admitted to two

New Zealand north island hospitals with a diagnosis ofMI who had subsequently been referred for phase twoCR Participants were obtained through purposive andtheoretical sampling Ten women participated ranging inage from 50 to 89 years old Three participants hadexperienced more than one MI

Data collectionSemi-structured in-depth interviews were used to

obtain data Written informed consent was obtained priorto the first interview and with permission the interviewswere audio-taped All interviews were undertaken by the lead author Field notes were recorded after eachinterview providing key phrases descriptions of thesituations body language and events that occurred duringthe interview Field notes were then used as data (Glaserand Strauss 1967 Glaser 1978 Schrieber and Stern 2001)Data were also obtained through the use of theoreticalmemos during data analysis Interviews took place betweenSeptember 2001 and April 2002 Literature related to theemerging categories was included in the data analysis

Data analysisData were analysed using constant-comparative

analysis which involves the joint collection and analysisof data using lsquoexplicit coding and analytic proceduresrsquo(Glaser and Strauss 1967 p 102) Where possible eachinterview was analysed prior to the next interview All forms of data were coded and compared for instancesof the substantive categories Although complete datasaturation was not reached due to the small number ofparticipants and time constraints the core category and basic social process (BSP) were presented to theparticipants and also discussed with other women whohad attended CR

The women described complementarity and fit betweentheir experiences and the theoretical analysis An audittrail of theoretical memos and field notes was maintainedso that the process of analysis could be retraced Althougha substantive theory did not emerge from this researchvaluable insight into womenrsquos recovery was gained

FINDINGSThis study was based on an assumption derived from

literature and clinical experience that CR would havesome positive impact on womenrsquos recovery from an MIThis assumption was challenged in terms of the ways in which women framed their experiences of their MIespecially in relation to their pre-understandings of what an MI would be like their understandings of theirtreatment in terms of hospital admission and the effectsthat those experiences had on their recovery These factorsall then impacted on what the women thought CR wouldentail and how it would meet their needs

RESEARCH PAPER

22

Why me Finding something to blame

What does recovery mean

Restricted roles


The way that CR contributed to overall recovery variedfor each participant and therefore was not a reliable factorin recovery Considering the way phase one CR isincluded in the acute hospital treatment it was notsurprising that most participants were unaware that thishad been part of their care

Eight of the ten participants attended some or all ofphase two CR although some participantrsquos attendancewas prevented by physical access issues work pressuresand co-morbidities which affected for example theirmobility These barriers are important considerations asthey reflect how the complexity of womenrsquos lives wasunable to be accommodated in the programs Women inpaid employment also struggled to attend during workhours when they had recently returned to work Margaretprovides an example of this

lsquoThe fact that I work up here isnrsquot a great deal of helpbut I am going to try work permitting to take Wednesdaysoff and thatrsquoshellipthatrsquos the day they had the meetings hereand certainly go to the next one at least and then Irsquoll seeIrsquoll see how I feel about it you know whether I think it isworthwhile to go again or whether itrsquos notrsquo (Margaret)

The phase two CR focused on information and adviceabout making lifestyle changes such as increasingexercise smoking cessation and dietary changes andinformation about risk factors and those that may havecontributed to the cardiac event Participants identifiedhow this advice did not include information about howthese changes could actually be implemented Forexample women were informed of the dietary changesthey should make but at home they were responsible forpreparing food for others who did not want to make thosechanges making it harder to modify their lifestyle

lsquoMy daughter rang up said lsquomum I need to lose weightbut I canrsquot do it and it wouldnrsquot hurt you eitherrsquo and I saidlsquonorsquo so we are going to Weight Watchers which ishellipyeah alot better But when you have got somebody (husband) in

the house that likes their sausages eggs and chips andthings like that it makes it very difficultrsquo (Beth)

Although the content of different CR programs wassimilar the information covered varied greatlyParticipants reported that they did not ask questionsduring group sessions because they did not feelcomfortable and some believed they only had theirquestions answered because others in the group mostoften men asked for the same sort of information

Most participants felt that the CR nurses had moretime to spend with them than general ward nurses andthis made them appear more approachable However therewas a noticeable difference in the amount and type ofsupport offered by CR nurses to different participants andthis support did not appear to be related to individualrsquosperceptions of their need For example four participantswere visited at home by the CR nurse at least once oneparticipant was visited three times and six were notvisited at all

Participants also expressed a need for peer support thatwas not met by attending phase two CR Feelings ofisolation were expressed by several participants who feltthey had nothing in common with the other people in theirCR group

lsquoI just thought it would be nice talking to someone inthe same boat as I was but there wasnrsquot you know as Isaid they have all had bypasses and angiograms andpacemakers nobody was in my boatrsquo (Beth)

No participants mentioned attending or being referredto a phase three CR program

The BSP which emerged from the data was that oflsquoreframingrsquo which was central to the recovery process andallowed most of the participants to fit their MI into theirlives The disruption to everydayness caused by sufferingan MI affected roles and responsibilities in ways that wereunique to each individual

RESEARCH PAPER

23

Figure 1 Reframing A continuum of recovery

Women donrsquot have heart attacks

Is this a heart attack

Interrupted activities

REFRAMING

SIGNIFICANCE OF SYMPTOMS DICHOTOMY OF RECOVERY REGAINING EVERYDAYNESS

Coping with other illnesses

Carrying on

Being supported

Disruption of everydaynessSuffering a heart attack Regaining everydayness

Phase 2 Cardiac RehabilitationPhase 1 Cardiac Rehabilitation


It is clear from findings that recovery was not astationary or rapidly occurring process for these womenrather it seemed to exist on a continuum (figure 1)beginning before MI symptoms were recognised andextending through to lsquoregaining everydaynessrsquo Theparticipants in this study identified with different stageson this continuum

For some the process of lsquoregaining everydaynessrsquoinvolved returning to the life they had before their MI Forothers it involved adapting to a new lsquoeverydaynessrsquo Therewas no specific timeframe for this process however itwas clear from the data that some participants who hadexperienced their MI two or three years before beinginterviewed were still working toward this goal Becauseof the limited time frame of CR it is clear that phase oneand two CR did not support this continuing recovery Noparticipants were involved in phase three CR thereforeany benefits this may give have not been investigated

Regaining everydayness was more difficult forparticipants when they did not attribute their symptoms to an MI Attending CR did not necessarily changeperceptions of symptoms and causes becauserehabilitation information tended to focus on the classicsymptoms and most participants in this study did notexperience these symptoms Instead some participants felt they were unusual or atypical and one reported havingdifficulty accepting that she really had suffered an MI Other illnesses often seemed to cause more disruption than the MI symptoms they experienced which created confusion

Participants also wanted to know why they hadsuffered an MI and what it would mean to their lives CRprograms assisted this by providing information aboutpossible causes which participants were able to use toidentify a possible cause for their own MI Participantsblamed factors such as smoking stress inheritedtendencies and medications

lsquoAs I say I attributed it to stress because I have got a

very sick husband (hellip) I have got to do all the thinking

for him and see to everything so I have a fair old burden

on my shoulders and I think that contributed you know

together with my daughter to my heart attackrsquo (Elizabeth)

The participants went through a process of reframingthat involved recognising the significance of theirsymptoms working out what recovery meant for themand attempting to lsquoregain everydaynessrsquo CR contributedto this process in varying degrees by providinginformation about their illness and education on waysthey could reduce their risk of further heart problems It isapparent however that with or without CR all of thewomen in this study lsquorecoveredrsquo to varying degrees

DISCUSSION AND IMPLICATIONS FORCARDIAC REHABILITATION

The findings of this study provide useful insights intothe role that CR plays in womenrsquos recovery from an MIIn order to lsquoregain everydaynessrsquo the women in this studyhad to lsquoreframersquo their lives to incorporate their MIexperience To do this it was necessary to recognise thesignificance of their symptoms and establish what hadcaused their MI CR provided them with someinformation related to possible causative factors andhelped to explain what had happened to them

However this focus on the risk factors associated withan MI and modification of these factors also implies thatthe individualrsquos behaviour can be blamed This blamingmay occur whether or not the individual health careprofessional actually blames the patient because thelanguage used contributes to the presumption thatresponsibility for the illness lies with the patient(Gunderman 2000) Health professionals need to be awareof the potential for blaming and actively work against this

Some of the participants in this study were not advisedto attend phase two CR Women who wish to attendorganised programs should be supported to do soLiterature identifies reasons for not attending CRincluding transport issues work and family commitmentsand feelings of having nothing in common with the group(Filip et al 1999 Mcsweeney and Crane 2001 Scott2003) and these were also issues for participants in thisstudy It is clear that CR needs to be flexible to meet theneeds of individual clients

The desire of women to return to lsquoeverydaynessrsquo mustalso be taken into account Supporting women to regaintheir everyday roles and responsibilities may make themfeel more positive Burell and Granlund (2002) suggestthat single gender groups may enhance the therapeuticefficacy of CR and improve womenrsquos participation

Although participants in this study generally feltpositive about the phase two CR it is clear it did not meetall their needs Of particular concern was that lack ofemotional support for recovery Moore (1996) found thatwomen wanted more emotional support from healthprofessionals Research examining the lifestyle changesof women post MI identified social support as aninhibitor and facilitator for making changes in healthbehaviour (Crane and McSweeney 2003 McSweeney andCoon 2004) Health professionals need to have a greaterawareness of the individual needs of women who haveexperienced an MI including acknowledging thatalthough health professionals have expert knowledge andskills which can be applied to the rehabilitation ofwomen who have experienced an MI the womenthemselves are also experts (Kamwendo et al 1998)Participants tended to attend phase two CR soon afterhospital discharge at a time when they were trying toreturn to their normal roles and possibly as a result

RESEARCH PAPER

24


CR seemed to slow their return to normal life rather thanassisting it

CR has been developed from research basedpredominantly on male populations (Brezenka and Kittle1996 Wenger and Hellerstein 1992) and therefore fails tomeet the specific needs of many women For participantssuffering an MI caused feelings of surprise and shockMost did not attribute their symptoms to an MI and thesymptoms experienced were significantly different tothose that are publicised as the lsquoclassic symptomsrsquoDespite much research recognising that women mayexperience symptoms that are different or less severe thanthey expect (Dempsey et al 1995 Dracup et al 1997Johnson and King 1995 LaCharity 1999 Murray et al2000) public health literature still presents informationabout lsquoclassicrsquo symptoms (NHFA 2004 NHFNZ 2004Revington 2004) There is a need to provide both womenand health care professionals with more education relatedto the signs and symptoms of heart disease in women sothat they are able to recognise the significance of suchsymptoms (OrsquoFarrell et al 2000) There also needs to bean educational focus on women sufferers of CHD in themedia rather than the current focus on men

CONCLUSIONCHD is currently a major health issue for women and

will continue to be so in the foreseeable future due todemographic changes and lifestyle factors In this studythe impact of CR on womenrsquos recovery from an MI wasvariable especially in helping women reframe and regaineverydayness Programs did not meet womenrsquos needs foreducation or support and CR needs to be flexible enoughto meet individual and group needs

Further research into how health professionals assessthe education and support needs of women is necessaryResearch investigating factors which help or hinderwomenrsquos recovery as well as the effect of roles andresponsibilities on womenrsquos recovery from an MI wouldalso be of value As currently structured CR does notmeet the needs of women because it appears to be basedon an assumption that everybody needs the sameinformation and support This study clearly shows thatone size does not fit all

REFERENCES Adams KL Barnard KL Swank AM MannE Kushnick MR andDenny DM 1999 Combined high-intensity strength aerobic training in diverse phase 2 cardiac rehabilitation patients Journal of CardiopulmonaryRehabilitation 19(4)209-215

Ades PA Waldman ML Polk DM and Colfesky JT 1992 Referralpatterns and exercise response in the rehabilitation of female coronary patientsaged greater than or equal to 62 years American Journal of cardiology69(17)1422-1425

Allen JK Scott LB Stewart KJ and Young DR 2004 Disparities inwomenrsquos referral to and enrolment in outpatient cardiac rehabilitation Journalof General Internal Medicine 19(7)810-811

American Heart Association 1998 What is cardiac rehabilitation availablewwwamericanheartorgdownloadableheart11006561877204520WhatIsCardiacRehabpdf (accessed 07082006)

Brezinka V and Kittel F 1996 Psychosocial factors of coronary heart diseasein women a review Social Science and Medicine 42(10)1351-65

Burell G and Granlund B 2002 Womenrsquos hearts need special treatmentInternational Journal of Behavioural Medicine 9(3)228-242

Burns KJ Camaione DN Froman RD and Clark BA 1998 Predictors of referral to cardiac rehabilitation and cardiac exercise self-efficacy ClinicalNursing Research 7(2)147-163

Cannistra LB Balady GJ OrsquoMalley CJ Weiner DA and Ryan TJ 1992Comparison of the clinical profile and outcome of women and men in cardiacrehabilitation American Journal of Cardiology 69(16)1274-1279

Cochrane BL 1992 Acute myocardial infarction in women Critical CareClinics of North America 4(2)279-289

Conn VS Taylor SG and Casey B 1992 Cardiac rehabilitation programparticipation and outcomes after myocardial infarction Rehabilitation Nursing17(2)58-63

Crane PB and McSweeney JC 2003 Exploring older womenrsquos lifestylechanges after myocardial infarction Medical Surgical Nursing 12(3)170-176

Day W 2003 Reframing everydayness A grounded theory study of womenrsquosperceptions of the contribution of cardiac rehabilitation to their recovery from aheart attack Unpublished Masters Thesis Massey University Palmerston North

Dempsey SJ Dracup K and Moser DK 1995 Womenrsquos decision to seek care for symptoms of acute myocardial infarction Heart and Lung24(6)444-456

Dinnes J 1998 Cardiac rehabilitation Nursing Times 94(38)50-51

Dracup K McKinley S and Moser DK 1997 Australian Patientsrsquo delay in response to heart attack symptoms The Medical Journal of Australia166(3)233-236 httpwwwmjacomaupublicissuesmar3dracupdracuphtml

Everson K Rosamond WD and Luepker RV 1998 Predictors of out patientcardiac rehabilitation utilization the Minnesota heart survey registry Journal ofCardiopulmonary Rehabilitation 18(3)192-198

Filip J McGillen C and Mosca L 1999 Patient preferences for cardiacrehabilitation and desired program elements Journal of CardiopulmonaryRehabilitation 19(6)339-343

Glaser B 1978 Theoretical sensitivity advances in the methodology ofgrounded theory Mill Valley The Sociology Press

Glaser B and Strauss A 1967 Discovery of grounded theory strategies forqualitative research New York Aldine DeGuyter

Gunderman R 2000 Illness as failure blaming patients Hastings Centre Report30(4)7-14

Guzzetta CE and Dossey BM 1992 Cardiovascular nursing holistic practiceSt Louis Mosby Year Book

Halm M and Penque S 1999 Heart disease in women American Journal ofNursing 99(4)26-31

Halm M Penque S Doll N and Beahrs M 1999 Women and cardiacrehabilitation referral and compliance patterns Journal of CardiovascularNursing 13(3)83-92

Higginson R 2003 Women are neglected when it comes to cardiacrehabilitation British Journal of Nursing 12(12)713

Johnson J and King K 1995 Influence of expectations about symptoms ondelay in seeking treatment during a myocardial infarction American Journal ofCritical Care 4(1)29-35

Kamwendo K Hansson M and Hjerpe I 1998 Relationship betweenadherence sense of coherence and knowledge in cardiac rehabilitationRehabilitation Nursing 23(5)240-245

LaCharity L A 1999 The experiences of younger women with coronary arterydisease Journal of Womenrsquos Health Gender Based Medicine 8(6)773-785

Lavie CJ and Milani RV 1995 Effects of cardiac rehabilitation and exercisetraining on exercise capacity coronary risk factors behavioural characteristicsand quality of life in women The American Journal of Cardiology 75(5)340-343

Lavie CJ and Milani RV 2000 Disparate effects of improving aerobicexercise capacity and quality of life after cardiac rehabilitation in young and elderly coronary patients Journal of Cardiopulmonary Rehabilitation20(4)235-240

McSweeney JC and Coon S 2004 Womenrsquos inhibitors and facilitatorsassociated with making behavioural changes after myocardial infarctionMedical Surgical Nursing 13(1)49-56

McSweeney JC and Crane PB 2001 An act of courage womenrsquos decision-making processes regarding outpatient cardiac rehabilitation attendanceRehabilitation Nursing 26(4)133-140

RESEARCH PAPER

25


Mitchell R Muggli M and Sato A 1999 Cardiac Rehabilitationparticipating in an exercise program in a quest to survive RehabilitationNursing 24(6)236-270

Moore SM 1996 Womenrsquos views of cardiac rehabilitation programs Journalof Cardiopulmonary Rehabilitation 16(2)123-129

Murray JC OrsquoFarrell P and Huston P 2000 The experiences of women with heart disease what are their needs Canadian Journal of Public Health91(2)98-102

National Heart Foundation of Australia 2004 Recommended framework for cardiac rehabilitation available wwwheartfoundationcomaudownloadsCR_04_Rec_Finalpdf (accessed 07082006)

National Heart Foundation of Australia 2004 Heart diseases and conditionsheart attack available httpwwwheartfoundationcomauindexcfmpage=185(accessed 07082006)

National Heart Foundation of New Zealand 2000 Cardiac care rehabilitationdirectory Auckland New Zealand

National Heart Foundation of New Zealand 2004 Signs and symptoms availablehttpwwwnhforgnzindexaspPageID=2145825888 (accessed 07082006)

Naughton J Dorn J and Imamura D 2000 Outcomes measurement incardiac rehabilitation the national exercise and heart disease project Journal ofRehabilitation and Outcomes Measurement 4(4)64-75

New Zealand Guidelines Group 2002 Evidence-based best practice guidelinecardiac rehabilitation Wellington New Zealand Guidelines Group

New Zealand Health Information Service 2003 7th May 2003 Mortalitystatistics totals for 1998 and 1999 New Zealand Health Information Serviceavailable wwwnzhisgovtnzstatsmortstatshtml

OrsquoFarrell P Murray J and Hotz SB 2000 Psychologic distress amongspouses of patients undergoing cardiac rehabilitation Heart and Lung29(2)97-104

Parks D Allison M Doughty R Cunningham L and Ellis CJ 2000 Anaudit of phase II cardiac rehabilitation at Auckland hospital New ZealandMedical Journal 113(1109)158-161

Petrie KJ and Weinman JA 1997 Perceptions of health and illnessAmsterdam Harwood Academic Publishers

Revington M 2004 The head rules the heart New Zealand Listener193(3337)16-21

Schreiber RS and Stern PN (eds) 2001 Using grounded theory in nursingNew York Springer

Scott I A 2003 Utilisation of outpatient cardiac rehabilitation in QueenslandMedical Journal of Australia 179(7)341-345

Tobias M 2001 The burden of disease and injury in New Zealand WellingtonNew Zealand Ministry of Health

Wallwork M 1996 Targeting women for cardiac rehabilitation Health Visitor69(5)179-180

Wenger NK Froelicher ES Smith LK Ades PA Berra K BlumenthalJA Certo CM Pattilo AM Davis D and DeBush RF 1995 Cardiac Rehabilitation Clinical Guideline No17 available wwwahrqgovresearchoct95dept6htm

Wenger NK and Hellerstein HK 1992 Rehabilitation of the coronarypatient New York Churchill Livingstone

World Health Organisation 1993 Rehabilitation after cardiovascular diseasewith special emphasis on developing countries (831) Geneva World Health Organisation

RESEARCH PAPER

26


ABSTRACT

Objective

To improve access to clinical information for nurses and doctors providing after hours communitypalliative care in a regional Australian setting

Design

This was an action research project designed toimprove collation and distribution of succinctpertinent and timely information about unstablepalliative care patients to nurses and generalpractitioners (GPs) involved in after hours careEach week day each patientrsquos purpose-designed single-page information sheet was updated on the community palliative care service computersThis sheet was designed to give key abstractedinformation on each patientrsquos history currentcondition treatment and plans for future carePatients considered to be unstable had their sheetsfaxed to the GPs on call

Setting and Subjects

This procedure was followed for all adult patientsadmitted to Ballarat Hospice Care Inc VictoriaAustralia between June and August 2004 The nursesand Executive Officer at Ballarat Hospice Care Inc and thirteen GPs from the Ballarat and DistrictDivision of General Practitioners were involved in the study

Main outcome measures

Surveys and feedback from palliative care nursesand GPs

Results A one-page information sheet provided essential

clinical information to nurses and doctors The nursesrsquoconfidence markedly increased with ready access tothe information sheets on a hand held Palm PilotTMThe nurses also reported improved outcomes forpatients using this approach and there was favourablefeedback from GPs

Conclusions This project led to the development of a simple

effective and low cost means of improvingcommunication between professionals caring forpalliative care patients after hours

AcknowledgementThe authors sincerely thank the William Buckland

Foundation for the financial support provided for thisand other research projects in palliative care in theGrampians Regional Palliative Care Service BallaratVictoria Australia

INTRODUCTIONThe literature reveals that problems exist in the

provision of palliative care interventions after hours andthat some of these problems may relate to lack of up-to-date clinical information This suggests that a studydesigned to improve access to information about clinicalissues may enhance patient nurse and general practitioner(GP) satisfaction with the process of care

This project aimed to develop an efficient affordablemodel for provision of after hours clinical information forthe after hours care of palliative care patients in theservice region of Ballarat Hospice Care Inc VictoriaAustralia which might be generalisable to other areasrsquoservices who do not have such a system

David Brumley MBBS FRACGP FAChPM MSc ClinicalDirector Gandarra Palliative Care Unit Ballarat Health ServicesBallarat Hospice Care Inc Palliative Care PhysicianDirectorGrampians Regional Palliative Care Research Centre BallaratVictoria Australia

John Fisher MSc MEd PhD Senior Research Fellow Centrefor Palliative Care St Vincentrsquos Hospital and University ofMelbourne Research Manager Grampians Regional PalliativeCare Research Centre Ballarat Victoria Australia

johnfibhsorgau

Heather Robinson BAppSc(Nurse) GradDipMan DipGerontExecutive Officer Ballarat Hospice Care Inc Victoria Australia

Michael Ashby MD MRCP FRCR FRACP FAChPMFFPMANZCA Professor and Director Centre for Palliative CareSt Vincentrsquos Hospital and University of Melbourne VictoriaAustralia


IMPROVING ACCESS TO CLINICAL INFORMATION IN AFTER HOURSCOMMUNITY PALLIATIVE CARE

RESEARCH PAPER

Key words improving communication patient outcomes essential medical data nurse confidence


Domiciliary Palliative CarelsquoPalliative care is care provided for people of all ages

who have a progressive life limiting illness with little orno prospect of cure and for whom the primary treatmentgoal is quality of lifersquo (Palliative Care Australia 2004p4) Patients admitted to domiciliary palliative careservices spend most of their last year of life at homeDomiciliary nurses and GPs provide most of the palliativecare to these patients and high quality well co-ordinatedcare is essential for the best outcomes (Mitchell 2002)

The provision of nursing medical and other supportsto palliative care patients at night and after normalworking hours is frequently problematical In a review ofout-of-hours palliative care in the United Kingdom (UK)Thomas (2000) reported four main areas of concern

bull communication

bull reduced access to support services

bull reduced access to medical advice

bull reduced access to drugs and equipment

In developing a framework for the improvement ofhome care for the dying in the UK - the lsquoGold StandardsFrameworkrsquo ndash Dr Keri Thomas observed that a majorlimitation to effective care at home is the fallibility oforganisational systems (2003)

Information RequiredThe extent of the information required for optimum

home and after hours care of the palliative care patientappears to be boundless yet there is a practical limit tothe amount of information that can be effectivelydocumented and shared In a discussion of the needs indomiciliary palliative care teamwork in Perth Smith andYuen (1994) agreed that the following information fromthe treating GP was essential to the team

bull history

bull current clinical condition

bull current medications

bull patientrsquos understanding of the disease process

bull patientrsquos understanding of prognosis and

bull patientrsquos expectations of care

To this we would add that effective palliative care alsorequires anticipation by experienced practitioners ofevents or crisis situations that can reasonably be foreseenin a given clinical situation (King et al 2003)

It is essential to have accurate reliable and wellpresented medical information with an up-to-date drughistory Access to hospital discharge summaries andletters is also vital Palliative care philosophy requires thatcare should include respect for the decisions which have been made about preference for site of care andapproach to end-of-life Thus the documentation shouldideally include information regarding these issues

appropriate contact information and the existence of anyadvance directive or Medical Power of Attorney It shouldbe standard practice to provide emergency medicationsfor home use and information about the availability ofthese when necessary

Information TransferThe transfer of up-to-date information about patients

between doctors and nurses is a generally acknowledgedproblem (Burt et al 2004) Although Australian literatureon the subject is limited GPs in Victoria report problemswith on-call and after hours support when they have tomake decisions without medical records being readilyavailable Patient-held records solve some aspects of theproblem but they do not solve the immediate access toclinical or social information for the GP or specialistwhen contacted by a nurse at home after hours (Shipmanet al 2000)

The method of information transfer must be adapted toindividual need and involve minimum effort for thepractitioner A totally web-based solution is unlikely to beeffective (King et al 2003) for even if such access isavailable it will not provide immediate information to thedoctor or nurse at night Neither nurse nor doctor is likelyto want to access the web for the information when wokenfor advice especially in the early hours of the morning

Grampians Health Region and Ballarat Hospice CareInc (BHC)

The Grampians Health Region is one of five ruralregions in Victoria covering an area of 48000 km2Ballarat is the largest city and the tertiary referral centrefor the region which had a population of 215536 in2001 There were 425 referrals to the four domiciliarypalliative care services in the region in 2003 with 413 admissions accepted and approximately 140registered clients at any one time (personalcommunication Executive Officer BHC November2004) Ballarat Hospice Care Inc provides after hoursemergency nursing service to patients in the city ofBallarat and immediate surroundings This service caresfor about half of all the palliative care patients in theGrampians Health Region

Concerns over communication within Ballarat HospiceCare catchment

Ballarat Hospice Care nurses commence a shift with averbal handover of unstable patients and they have accessto a clinical nursing summary and list of drugs They donot always have ready access to a medical summaryproduced by the palliative care physician andor lettersfrom other consultants Palliative care nurse specialistsreport consistent difficulty in accessing clinicalinformation about the patients for whom they care

International and Australian literature indicates that GPs generally find it satisfying to be involved in palliativecare but they nearly all agree that communication is a major issue (Munday et al 1999 Yuen et al 2003)

RESEARCH PAPER

28


The transfer of information about individual patients andproblems usually relies on informal telephone callsbetween doctors and nurses Discussions with Divisionsof GPs within the region indicate that they see improvedtransfer of information as an area of need which isaddressed in this project

This project aimed to improve communication betweenexisting service providers with minimal extra effort andcost It planned to provide a summary sheet for eachpatient based on a slight modification of the existingmedical records used by the palliative care nurses Thisproject planned to coordinate the information transferusing the services of a medical receptionist to contactrelevant GPsrsquo offices taking one to two hours per day to keep local GPs closely connected with the care of their patients

METHOD

Objective

To improve access to clinical information for nursesand doctors providing after hours community palliativecare in a regional Australian setting

Design

Action research allows nurses to participate in researchin the local setting providing ample opportunity for re-evaluation and feedback (McGarvey 1993 p372) A variety of approaches definitions and uses of actionresearch have emerged since it was created by Kurt Lewin(Holter and Schwartz-Barcott 1993 p298) This projectemployed a five-step action research process outlined byMcGarvey (1993 p375) which

i) identified a problem in distributing timely andappropriate information about unstable palliativecare patients to nurses and general practitionersinvolved in after hours care and

ii) considered the problem through a literature searchwhich led to

iii) the proposed plan of action which was to surveynurses and GPs to develop a single page ofessential medical data relating to the history andcurrent condition of any unstable patients

iv) This plan was put into practice by transferring theinformation sheet by fax or secure computerlinkage each week day between nurses and GPsresponsible for the patientsrsquo after hours care

v) The reflective stage of the project consideredfeedback from the nurses and GPs to assess the value of the process and make recommendationsfor future action

Setting and subjectsAll adult patients admitted to Ballarat Hospice Care

Inc a domiciliary palliative care service in Victoria wereinvited to participate in this project between June andAugust 2004 so their medical information might beshared between professionals caring for them especiallyafter hours The nurses and Executive Officer at BHCand GPs from the Ballarat and District Division ofGeneral Practitioners were the professionals invited toparticipate in this study Ethics approvals were obtainedfrom Ballarat Health Services and BHC for this project

Main outcome measuresThe following outcome measures were planned to be

used in this study

bull palliative care nursesrsquo and general practitionersrsquosurveys and focus group feedback

bull the number of accurate predictions of unstablepalliative care patients that resulted in call-outs afterhours and

bull patient satisfaction survey following after hoursservice (from McKinley et al 1997)

The following results and discussion section will showthat the first outcome measure was very successful butthere was difficulty with the second and reasons aregiven as to why the third was not used

RESULTS AND DISCUSSION

Developing and using the After Hours Palliative CarePatient Information Sheet

The seven palliative care staff from BHC and thirteenof the general practitioners from the Ballarat and DistrictDivision of General Practice completed a survey whichled to the selection of information considered essential forhandover of palliative care patients This was recorded ona single A4 sheet called the After Hours Palliative CarePatient Information Sheet (see Appendix A for details)

It took approximately one hour to set up each newpatientrsquos file on the BHC computer As these files werebased on MS Word rather than a database they were veryeasy to process This procedure was very simpleefficient effective and cheap

King et al (2003 p279) found that lsquothe main problemreported was keeping the [hand over] forms up to dategiven the rapidity with which conditions can change inpalliative carersquo Although at least one nurse in King et alrsquosstudy said lsquoIt would be a nightmare to attempt to do it hellipdailyrsquo (2003 p279) the nurses in our study found itneeded to be done daily to be most relevant At the end ofeach week day following their visits to the palliative carepatients the PC nurses updated their nursing notes usingMS Word with desktop computers This information wasthen downloaded onto the BHC central computer

RESEARCH PAPER

29


After updating their notes the hospice nursesdiscussed the patients to predict which were unstableenough to possibly lead to call-outs after hoursInformation sheets for these patients were faxed to the GPknown to be lsquoon callrsquo for each patient that evening Thecurrent single-page information sheet together with thePalliative Care Nurse Consultantrsquos initial assessmentnotes any letters to GPs andor referrer specialistappointments hospital discharges etc were scanned intothe files for all patients and transferred to a Palm Pilot forthe Hospice nurse lsquoon callrsquo after hours

LIMITATIONS

Difficulty predicting call-outs for unstable patientsWhere the palliative care nurses considered a patientrsquos

condition or care situation to be unstable and hence likelyto result in an after hours call-out andor hospitaladmission the information sheet was sent to the generalpractitioner concerned Over eight weeks from 7 June to10 August 2004 29 of the patients registered with BHCwere sufficiently unstable which could have resulted in call-outs on 99 occasions Seventeen actual call-outsresulted from these 99 predictions In the same eight-week period there were another 36 after hoursrsquo call-outs which were not predicted This difficulty withaccuracy of prediction of call-outs reinforces the need tohave accurate up-to-date information readily availableafter hours

Patientsrsquo satisfaction surveyThe planned survey of palliative care patientsrsquo

satisfaction which referred mainly to after hoursrsquo serviceprovided by doctors was not undertaken as there wereonly four GPs who were called to attend palliative carepatients after hours during this study

Limited GP involvementOnly two of the four GPs who were called to attend

palliative care patients during the two months of thisstudy had been sent a copy of their patientsrsquo informationsheet This provided insufficient data to draw conclusionsHowever incidental feedback from several other GPswho had received the one-page information sheetsindicated that the information would have been useful hadthey been contacted about their patients after hours

Benefits for nursesAlthough only four GPs were involved in after hoursrsquo

call-outs for palliative care patients during this study thepalliative care nurses certainly gained benefit from itBelow are summaries of comments from a feedbackquestionnaire and a round-table discussion with the sixpalliative care nurses and the EO who participated in thisproject at BHC

After some initial concerns the nurses found theinformation sheets and computers easy to use and verybeneficial to their practice A simple MS Word-based

program was used which only demanded elementaryword processing skills rather than a more complexdatabase Updating the information sheets daily made thenurses more thorough in their reporting especially thesection on Expectations of Care where very specificcomments were noted

Nursesrsquo confidence markedly increased because theyhad immediate access to each patientrsquos

i full medical history vi risks and problemsii treatments vii symptom controliii current status viii contact informationiv up-to-date medications list ix doctorsrsquo letters andv progress notes x expectations of care

Nurses also saved time because they did not have to goto the office to collect patientsrsquo notes before eitherphoning back or visiting the patients after hours With thenurses on call having all relevant information on hand itmeant they could respond to the pager rapidly and giveaccurate information for all patients even those they hadnot previously seen This reduced nursesrsquo concerns orworry about not knowing patients and the patients did nothave to repeat their medical history to each new nursewho visited them

Nurses felt more confident with assessments whichled to patientsrsquo outcomes being improved due to nursesrsquoincreased knowledge For example reduced chances oferror when administering drugs in keeping with resultsfrom Bates and Gawande (2003) who found thatimproved communication and readily accessibleknowledge prevented errors and adverse events Althoughnurses still needed to contact GPs for drug orders therewas a feeling that there was lsquoless need to call for help [asnurses were] better equipped [and could] pick upproblems more accuratelyrsquo

Nurses could give more thorough information to GPsand Accident and Emergency staff when necessary tohelp provide more sound medical treatment for theirpatients The nurses reflected this also helped thempresent as being more professional in their practice withother medical colleagues Nurses could confidently tellthe doctors to lsquocall back if more information is neededrsquoknowing they would be able to provide currentinformation as it was readily available (on a Palm Pilot inthis study)

Problems and future developmentWith a considerable amount of new information

coming in each day to be updated on computers it wasdifficult to restrict it to one page (see Appendix A) whichwas done in order to facilitate faxing to GPs In future

i without the need to fax a single sheet to GPs thenotes can be extended to more than one page

ii the bottom of the information sheet will be used formedications and long history

RESEARCH PAPER

30


iii the lsquosymptoms severity 1-10rsquo will not be usedunless there is a drastic change so this list will beused as a check list for lsquocurrent problemsrsquo withthe addition of lsquofatiguersquo (see Appendix A)

The minor duplication of nursing notes whichoccurred in this study will be reduced when each nursehas a desktop computer and Palm Pilot which BHC hasdecided to implement due to the success of this projectWhen they each have a Palm Pilot the nurses will be able to enter notes directly during home visits This willfacilitate the processing of information to update eachpersonrsquos records on a daily basis when the nurses returnto Hospice

This study provided a single sheet of salient informationon a Word-based program This would work on a laptop ora personal computer accessible by mobile phone as wellas on the Palm Pilot The message not the medium is thekey finding in this project

CONCLUSIONThe palliative care nurses in this study reported

improved outcomes for patients due to the nursesrsquo moreconfident approach based on better knowledge about thepatientsrsquo history current condition and treatments andplans for future care

Informal feedback from GPs who received the faxes ontheir patients found the information to be valuable eventhough it was not needed for after hours call-outs by manyGPs in this study

Although there was some initial uncertainty among thepalliative care nurses about filling in the informationsheet and implementing a computer-based recordingsystem for palliative care patients once they quicklybecame used to the simple MS Word-based programstoring the data from the comprehensive informationsheet they found it to be remarkably convenient veryeffective efficient and empowering

Having ready access to each patientrsquos

i full medical history vi risks and problemsii treatments vii symptom controliiicurrent status viii contact informationiv up-to-date medications list ix doctorsrsquo letters andv progress notes x expectations of care

markedly increased the palliative care nursesrsquo confidencein working with the patients their peers and other medical personnel

These benefits to practice were delivered at a low cost

The system developed in this study is simple readily

accessible and available free of charge from the authors It

should be emphasised that the abstracted information

sheet used in this study does not remove the need to

record fuller clinical data from initial patient assessment

and progress monitoring nor does it generate data Many

systems now integrate clinical information and data

gathering functions in the one information technology

database system This increases staff work load and cost

considerably and may or may not meet the out-of-hours

needs of a service which was the aim here

REFERENCESBates DW and Gawande AA 2003 Patient safety improving safety with Information Technology The New England Journal of Medicine 348(25)2526-2534

Burt J Barclay S Marshall N Shipman C Stimson A and Young J 2004 Continuity within primary palliative care an audit of general practice out-of-hours co-operatives Journal of Public Health 26(3)275-276

King N Thomas K and Bell D 2003 An out-of-hours protocol forcommunity palliative care practitionersrsquo perspectives International Journal of

Palliative Nursing 9(7)277-282

McGarvey H 1993 Participation in the research process action research innursing Professional Nurse 8(6) 372-376

McKinley RK Manku-Scott T Hastings AM French DP and Baker R1997 Reliability and validity of a new measure of patient satisfaction with outof hours primary medical care in the United Kingdom development of a patientquestionnaire British Medical Journal 314(7075)193-198

Mitchell GK 2002 How well do general practitioners deliver palliative careA systematic review Palliative Medicine16(6)457-464

Munday D Douglas A and Carroll D 1999 GP out-of-hours cooperativesand the delivery of palliative care British Journal of General Practice49(443)489

Palliative Care Australia 2004 Standards for Providing Quality Palliative Care

for All Australians (4th edn) Deakin West ACT PCA wwwpallcareorgauPortals9docsStandards20Palliative20carepdf

Shipman C Addington-Hall J Barclay S Briggs J Cox I Daniels L andMillar D 2000 Providing palliative care in primary care how satisfied are GPsand district nurses with current out-of-hours arrangements British Journal of

General Practice 50(455)477-478

Smith M and Yuen K 1994 Palliative care in the home the GPhome hospiceteam Australian Family Physician 23(7)1260-1265

Thomas K 2000 Out-of-hours palliative care bridging the gap European

Journal of Palliative Care 7(1)22-25

Thomas K 2003 The Gold Standards Framework in Community PalliativeCare European Journal of Palliative Care 10(3)113-115

Yuen KJ Behrndt MM and Mitchell GK 2003 Palliative care at homegeneral practitioners working with palliative care teams Medical Journal of

Australia 179(6)Suppl pp38-40

RESEARCH PAPER

31


RESEARCH PAPER

32

Appendix A After hours palliative care patient information sheet

Name

Address

Phone

UR No DOB

Carer Name Relationship Phone

GP Name Phone Fax

NOK Phone

Specialist

Brief History

Primary Diagnosis

Secondary Diagnosis

Current Clinical Condition

Stable Unstable Deteriorating Terminal

Current treatment

Symptoms Severity 1 -10

Pain 1 Anxiety

Pain 2 Depression

Nausea Vomiting Appetite

Drowsiness Constipation

Dyspnoea RestlessnessAgitation

Mobility [fatigue]

Current medications Allergies

Drug Name Dosage Route Recent changes Problems

Expectations of Care

Preferred place of care Preferred place of dying Treatment options

Patient

Carer

Last updated

BALLARAT HOSPICE CARE INC AFTER HOURS INFO SHEET


SCHOLARLY PAPER

ABSTRACT

AimThis paper reviews the nursing research literature

on chronic pain in the older person living in thecommunity and suggests areas for future research

BackgroundChronic pain is a pervasive and complex problem

that is difficult to treat appropriately Nursesmanaging chronic pain in older people indomiciliaryhomecommunity nursing settings facemany challenges To provide care the manyparameters of chronic pain which include the physicalas well as the psycho-social impact and the effect ofpain on patients and their families must be carefullyassessed Beliefs of the older person about pain andpain management are also important

MethodRelevant nursing studies were searched using

CINAHL Cochrane Database of Systematic ReviewsEMBASE and PUBMED databases using key wordsabout pain and the older person that were appropriateto each database

ResultsTools to assess pain intensity in the older person

have been studied but there has been less research onthe other parameters of pain assessment or how theolder person manages pain An effective nurse-patientrelationship is an important component of this processand one that needs more study Few research studieshave focused on how nurses can be assisted or on thechallenges nursesrsquo face when managing thisvulnerable population

ConclusionA broad approach at the organisational level will

assist nurses to manage this health care issue

AcknowledgementI would like to acknowledge the assistance of Paula

Tognazzini MSN Instructor and Post RN Advisor

University of British Columbia School of Nursing andKathy Gregg MSc and Clarissa Tsang BSN ResearchAssistants in the preparation of this manuscript

INTRODUCTIONChronic pain is a significant health problem for older

people living in the community The prevalence rate isdifficult to determine but researchers in Australia andoverseas have found between 27 (Blyth et al 2001) and51 (Helme and Gibson 1997) of those over 65 yearsreport chronic pain In those 85 years and older theprevalence rates are higher as researchers report that asmany as 70 of older persons who live in communitysettings report pain (Brochet et al 1998 Roy and Thomas1987 Scudds and Robertson 2000) This high prevalenceis a concern as chronic pain particularly in the older personis not well-treated (Ferrell et al 1990 Pitkala et al 2002)

Chronic pain affects all aspects of an individualrsquos lifeand has a major impact on health services A Canadianstudy reported over 757 of older people receiving homenursing had been troubled by pain in the past two weeks(Ross and Crook1998) Managing chronic pain in theolder person is an important nursing responsibilityhowever most research that guides nursing practice hasbeen conducted in acute care or nursing home settingsNursing research about managing chronic non-malignantpain in non-institutionalised older persons is limited

The purpose of this paper is to review the nursingliterature on assessment and management of chronic painin older persons in a community setting and to suggestareas for further research

Relevant nursing studies in English were searched inelectronic databases up to July 2005 Neoplasms andpalliative care studies were excluded and a limit of age 65and older imposed Databases included CINAHL (1982-)using keywords aged chronic pain community healthnursing Cochrane Database of Systematic Reviewcombined aged chronic pain community care withcomplementary and alternative medicine EMBASE(1996 ndash) using keywords aged chronic pain and homeservices PUBMED (1967-) using MeSH terms agedpain pain assessment home care services

Anne Dewar RN PhD Associate Professor School of NursingWesbrook Mall Vancouver Canada

dewarnursingubcca

Accepted for publication December 2005

ASSESSMENT AND MANAGEMENT OF CHRONIC PAIN IN THE OLDER PERSONLIVING IN THE COMMUNITY

Key words Chronic pain older people domiciliaryhomecommunity care nurses pain assessment paininstruments


SCHOLARLY PAPER

34

LITERATURE REVIEW

Assessment of chronic painPain assessment in the older person is particularly

complex because of other underlying health issuespolypharmacy and increased sensitivity to pain-relievingmedications A range of other factors such as the patientrsquosbeliefs and attitudes toward pain and analgesicmedications health professionalsrsquo lack of knowledge andlack of understanding about the complexity of chronicpain and even organisational barriers add to the problemand complicate the nursersquos role Chronic pain affects all dimensions of an individualrsquos life physicalpsychological social and spiritual and data should begathered on all these aspects as well as the meaning ofpain for the individual

Chronic pain can interfere with the older personrsquosabilities to perform activities of daily living (ADLs) Indomiciliaryhomecommunity care settings researchershave found that older people with chronic pain requiremore assistance with ADLs from domiciliaryhomecommunity care nurses than those who are pain free(Ross and Crook 1998) Chronic pain can also affectappetite (Bosley et al 2004) and sleep (Ferrell et al 1990Ross and Crook 1998)

Researchers in other fields have noted that painintensity has the most impact on the older personrsquosphysical functioning but other pain characteristics whichinclude location onset duration frequency and pattern(continuous or intermittent) also have an effect Forexample pain that is continuous but of moderate intensitycan be just as disabling as severe pain that is intermittent(Lichtenstein et al 1998) (Disability is defined asdifficulty performing three or more activities of dailyliving) Level of disability also increases if more than onebody site is affected (Lichtenstein et al 1998) Falls in theolder person have also been linked to chronic pain (seeVarela-Burstein and Miller 2003 for a review) andalthough all the particulars of the association are notclearly understood it is postulated that pain may causeindividuals to modify their ADLs These modificationscan lead to problems of balance and loss of physical conditioning which can predispose to fallsPharmacotherapy used for sleep and for pain relief maycontribute to falls also

In the older population nursing investigators havefocused on which tools measure pain intensity accuratelyIn community settings assessment tools have beenstudied to determine if some instruments are too abstractparticularly when cognition is a problem The followingtools have been researched using older persons incommunity settings as the population verbal descriptorscales (VDS) (Benesh et al 1997 Herr et al 2004 Taylorand Herr 2003) the vertical visual analogue scale VAS[v-VAS] (Benesh et al 1997 Herr et al 2004) temperaturescales (PT) (Benesh et al 1997 Taylor and Herr 2003)numerical rating scales (NRS) (Benesh et al 1997 Taylor

and Herr 2003 Herr et al 2004) verbal numerical ratingscale (VNS) (Herr et al 2004) and faces pain scales(FPS) (Herr et al 1998 Herr et al 2004 Taylor and Herr2003) Several researchers have concluded that thesecommonly used tools are valid and reliable for olderpersons and many are suitable for those with mild tomoderate cognitive impairment (Ferrell et al 1995 Taylorand Herr 2003) if special provisions such as enlargedprint and careful explanations are made (Taylor and Herr 2003)

There is less research on assessing the impact ofchronic pain on the psychosocial well-being of the olderperson living in the community Chronic pain caninterfere with the older personrsquos ability to shop maintaintheir home and with family and social relationships (Rossand Crook 1998 Mobily et al 1994) The risk ofdepression increases with chronic pain (Carrington Reidet al 2003 Lin and Taylor 1999 Ross and Crook 1998)Because some of the symptoms of depression and chronicpain are similar nurses may need to use a mental statusquestionnaire such as the Mini-Mental StatusQuestionnaire (Folstein et al 1975) in conjunction withpain assessment measures to ensure that the patientreceives appropriate care (Herr and Mobily 1991)Cognition can be influenced by both pain and analgesics(McCaffery and Pasero 1999)

One of the difficulties associated with pain assessmentis that the older person may be reluctant to report painClinicians have suggested that stoic attitudes fears ofaging fears about medications fears that pain means theymay not recover are commonly held beliefs about painand pain management (Ferrell et al 1990 Herr andMobily 1991 Muonio 2004) Investigators in long-termcare settings suggest that the older person may not wantto bother nurses and believe that complaining mayalienate health professionals and drive away their limitedsocial support (Ferrell et al 1990 Yates et al 1995)Conversely some clinicians suggest that older personsmay report pain instead of other symptoms as pain ismore acceptable to report than physical losses lonelinessand boredom (Herr and Mobily 1991)

The language used by older persons to describe theirpain may differ as they may not refer to a problem as painbut instead use terms like soreness or annoying(Miaskowski 2000) Obtaining accurate pain reports fromthose with dementia is a concern

Maumlntyselka et al (2004) found that the older personwith dementia living in the community as assessed by ageriatrician reported less pain and used less analgesicsthan those who did not have dementia This suggests thatalthough persons with dementia do not report as muchpain nurses need to use other means to assess pain andprovide pain relief

Management of chronic painRecently there has been more attention to the

investigation of the older personsrsquo beliefs about pain and

SCHOLARLY PAPER

35

about their preferred methods of managing it (Jakobssonet al 2003 Ruzicka 1998 Tse et al 2005 Walker et al1990 Yates et al 1995) Ruzicka (1998) found a diversityof beliefs about causes of pain and pain management assome older persons view pain as something that they havesome control over and others believe that painmanagement requires assistance This researcher alsofound that older persons believe that being anxious ordepressed increases pain (Ruzicka 1998) Walker et al(1990) found that comprehensive data should be gatheredon the older personrsquos understanding of the cause of painmethods used for pain control as well as past life regretshow busy or occupied they are and any personalproblems experienced as these factors have a significantimpact on the patientrsquos ability to remain in control andcope with chronic pain

Chronic pain may require a combination of methods tomanage it successfully and older people prefer somemethods to others Swedish researchers found that onaverage older people used only three different methodsand amongst those living at home the most frequentlyused methods were prescribed medication rest anddistraction (Jakobsson et al 2003) However theirpreferred strategy varied with their living situation(Jakobsson et al 2003) as those who lived alone preferredexercise above prescribed medications whereas thoseliving with someone preferred to use heat aboveprescribed medications

Older persons may rely on and even prefer self-caretechniques such as home remedies massage non-prescription analgesics and cognitive techniques such asdistraction and rest to pain-relieving medicationsexercises or physiotherapy (Jakobsson et al 2003Landsbury 2000 Tse et al 2005) More investigation isneeded into the approaches used by older persons andtheir preferred strategies particularly as older persons arefrequently taking multiple prescription medications

Cognitive strategies used by older people living in thecommunity have not been investigated in depth Dunn andHorgas (2004) found that behavioral coping strategieswhich included reporting pain to physicians or nurseswere used more frequently than cognitive copingstrategies such as self-statements Religious copingstrategies were used by older women and older persons ofminority groups (Dunn and Horgas 2004) Ersek et al(2003) found that a self- management chronic painprogram can have a significant positive impact on theolder personrsquos pain intensity and ability to perform workand daily activities However access to these programsmay be an issue for the fragile older person

Research indicates clearly that having a supportiveindividual to talk to about pain is important to the olderperson (Dunn and Horgas 2004 Jakobsson et al 2003Walker et al 1990 Yates et al 1995) Older patients expectand want nurses to provide support and discuss painissues (Dunn and Horgas 2004 Walker et al 1990)

Emotional support is as important to patients as advice onprescribed treatments (Walker et al 1990)

Nursing issues in assessment and management ofchronic pain

Researchers have also suggested that factors in healthprofessionals are associated with poor pain assessmentand management McCafferyrsquos landmark work in the1960rsquos encouraged health professionals to believe thatpain was what the patientrsquos says it is (McCaffery 1968)However there is evidence that health professionals placetheir own interpretation on the patientrsquos pain Researchfrom domiciliaryhomecommunity care (Hall-Lord etal1999) and long term care settings (Katsma and Souza2000) indicates that health care professionalsunderestimate pain in the older person Walker et al(1990) found that the long-term contact with the olderpatient that occurs in domiciliaryhomecommunity caresettings did not positively influence the nursersquos estimatesof patientrsquos pain

Lack of knowledge of pain is often cited as a majorreason why nurses do not manage pain adequately inolder persons (see Brown 2004 for a review Brockopp et al 1993 Clarke et al 1996 Closs 1996 Watt-Watson1987) Most of this research has been done in acute caresettings but domicillaryhomecommunity care nurseshave identified that they need more knowledge aboutchronic pain management management of patientsrsquoco-morbid conditions and pharmacology to manage theolder personrsquos pain adequately (Glajchen and Bookbinder2001 Kee and Epps 2001 Laborde and Texidor 1996Toumlrnkvist et al 1998) Glajchen and Bookbinder (2001)noted that the nurses may not be aware that their painmanagement knowledge base is inadequate and mayoverestimate what they know More systematic explorationof the problems that nurses encounter and the strategiesthat nurses use to manage these problems is urgently needed

Research with older persons in the community hastried to determine if various patient characteristics (agegender marital status and culture) influence nursesrsquo painassessments Hall-Lord et al (1999) found that thepatientrsquos marital status has some influence as enrollednurses (LPNrsquos) overestimated pain in married patientsand underestimated pain in single patients (Hall-Lord etal1999) These researchers suggest that spouses maymake the nurses more aware of the patientrsquos pain and thusincrease the nursesrsquo ratings of patientsrsquo pain Cultureinfluences the way patients express pain and how nursesassess and manage it (Bell and Reeves 1999 Duggleby2003 Lasch 2000) There is a lack of research about thecultural aspects of chronic pain in older persons andfurther investigation is needed as this population may facefurther disadvantage by having language problems as well

Researchers have suggested that nursesrsquo attitudes andbeliefs as well as lack of knowledge may influence hownurses assess pain and provide analgesia (Clarke et al1996 Edwards et al 2001 Hamilton and Edgar 1992)



SCHOLARLY PAPER

36

The relationship between knowledge and attitudes indomiciliaryhomecommunity care settings has had only minimal investigation however Laborde and Texidor(1996) indicated that knowledge had a positive influenceon domiciliaryhomecommunity care nursesrsquo attitudesabout chronic pain management

Investigations into nursing interventions used to managechronic pain in domiciliaryhomecommunity nursingsettings are limited Walker et al (1990) found thatnursing interventions that help patients achieve controlover their pain are helpful Therapeutic touch significantlyreduced musculoskeletal pain and anxiety in an olderpopulation (Lin and Gill Taylor 1999) McCaffrey andFreeman (2003) used a randomized control trial todetermine that music therapy reduced pain levels ofcommunity-based patients with osteoarthritis Patienteducation has a role in pain management

Research with cancer populations in home nursingsettings identified that structured educational interventionshelped patients and families cope with cancer pain (Ferrellet al 1998) and reduced home care nursing cancer patientsrsquobarriers to reporting pain and using analgesia (Chang et al2002) Further investigation of the particular educationalneeds of older persons and their families with non-malignant pain would add to our knowledge in this field

Patients receiving nursing care at home expect nursesto advocate with physicians for their pain management(Ferrell and Dean 1994 Walker et al 1990) Laborde andTexidor (1996) found that domiciliaryhomecommunitynurses regard the physician as the prime source ofknowledge about pain management Investigators havefound that many general practitioners find managingchronic pain a challenge (Blum et al 1990 Weinstein et al2000) thus nurses need access to expertise in painmanagement such as pain specialists clinical nursespecialists and interdisciplinary pain managementprograms Often interdisciplinary pain managementprograms exclude older persons because of an age biasand a goal to rehabilitate those who can return to workAn Australian study established that the geriatricpopulation can benefit from these clinics (Helme et al1996) One American study found that domiciliaryhomecommunity nurses do not make use of these clinicscentres even as sources of advice to help patients withchronic pain (Laborde and Texidor 1996)

Organisational culture and management structures arecrucial to pain management but research on theircontribution is limited Organisations that manage painsuccessfully use a multiple pronged approach whichincludes protocols policies and assessment practices(Ferrell 1995 Weissman et al 2000) as well as a long-termcommitment to education In the community when nursepain-advisors were introduced as resource persons nursesfound that their assessment evaluation and documentationof pain in patients with leg ulcers improved (Toumlrnkvist et al2003) This low-cost management strategy also increasedthe nursesrsquo satisfaction with their care

SUMMARY AND CONCLUSIONSThere is an urgent need for more research about how

nurses care for the older person with pain in communitysettings A major research focus has been to determinewhich tools are appropriate to measure pain intensityAlthough pain intensity is an important basis fortreatment other factors also affect pain assessment andmanagement These factors include the impact of otherpain characteristics on the individualrsquos physical andpsychosocial functioning The effect of co-morbidconditions and the influence of patient and nursecharacteristics are also important influences on painassessment and management The nurse-patientrelationship is crucial but this relationship has not receivedmuch attention in pain management research Non-invasivenursing interventions also need more exploration

The beliefs concerns and practices of older personsabout pain also have a major impact on pain managementInterventions that assist older persons to develop andretain control of their pain management have improvedoutcomes but more investigation is required into theseareas As the rate of depression amongst older persons ishigh and can contribute to other physical symptoms suchas decreased mobility and limited social interaction it iscritical that the psychosocial needs of older persons withchronic pain be assessed These patients are often isolatedand the nurse may be one of their few contacts hence thenursesrsquo abilities to assess for and differentiate betweenpain and depression and to advocate for care are critical

Research-based information on the nursesrsquo needs andthe challenges they face when managing chronic pain inthe home is extremely limited The lack of evidence-basedinformation is even more significant given that nursesrsquoresponsibilities for managing this complex health problemhave increased From the exploration that has been donenurses need education tailored to address their specificknowledge needs about pain co-morbid healthconditions pharmacology and appropriate methods ofeducating older patients and their families Access toexpert advice such as clinical nurse specialists andavenues of referral to specialised pain managementprograms are also required along with organisationalstructures such as policies procedures and resources toaddress pain A multifactoral approach at all levels iscrucial Given the high prevalence of chronic pain in thispopulation and the impact upon patients families and the health care system this health care problem needs tobe addressed

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Benesh LR Szigeti E Ferraro F R and Naismith Gullicks J 1997 Toolsfor assessing chronic pain in rural elderly women Home Healthcare Nurse15(3)207-211


SCHOLARLY PAPER

37

Blum R H Simpson P K and Blum D S 1990 Factors limiting the use ofindicated opioid analgesics for cancer pain American Journal of Hospice andPalliative Care 7(5)31-35

Blyth FM March LM Brnabic AJM Jorn L R Williamson M andCousins MJ 2001 Chronic pain in Australia A prevalence study Pain89(1-2)127-134

Bosley BN Weiner DK Rudy TE and Granieri E 2004 Is chronicnonmalignant pain associated with decreased appetite in older adultsPreliminary Evidence Journal of the American Geriatric Society 52(2)247-251

Brochet B Michel P Barberger- Gateau P and Darcigues J 1998Population-based study of pain in elderly people a descriptive survey Age andAgeing 27(3)279-284 Brockopp G Warden S Colclough G and BrockoppG 1993 Nursing knowledge acute postoperative pain management in theelderly Journal of Gerontological Nursing 19(11)31-37

Brown D 2004 A literature review exploring how healthcare professionalscontribute to the assessment and control of postoperative pain in older peopleJournal of Clinical Nursing 13(supplement 2)74-90

Carrington Reid M Wiliams CS Concato J Tinetti ME and Gill TM2003 Depressive symptoms as a risk factor for disabling back pain incommunity-dwelling older persons Journal of the American Geriatric Society51(12)1710-1717

Chang M Chang Y Chiou J Tsou T and Lin C 2002 Overcomingpatient-related barriers to cancer pain management for home care patientsCancer Nursing 25(6)470-476

Clarke EB French B Bilodeau ML Capasso VC Edwards A andEmpoliti J 1996 Pain management knowledge attitudes and clinical practicethe impact of nurses characteristics and education Journal of Pain andSymptom Management 11(1)18-31

Closs SJ 1996 Pain and elderly patients a survey of nursesrsquo knowledge andexperiences Journal of Advanced Nursing 23(2)237-242

Duggleby W 2003 Helping HispanicLatino home health patients manage theirpain Home Healthcare Nurse 21(3)174-179

Dunn KS and Horgas AL 2004 Religious and non-religious coping in olderadults experiencing chronic pain Pain Management Nursing 5(1)19-28

Edwards H Nash R Najman J Yates P Fentiman B Dewar AL Walsh AK McDowell J and Sherman H 2001 Determinants of nursesrsquointentions to administer opioids for pain relief Nursing and Health Sciences3(3)149-159

Ersek M Turner JA McCurry SM Gibbons Land Miller Kraybill B2003 Efficacy of a self-management group intervention for elderly personswith chronic pain The Clinical Journal of Pain 19(3)156-167

Ferrell B 1995 Pain evaluation and measurement in the nursing home Annalsof Internal Medicine 123(9)681-687

Ferrell B R Borneman T and Juarez G (1998) Integration of paineducation in home care Journal of Palliative Care 14(3)62-68

Ferrell B and Dean GE (1994) Ethical issues in pain management at homeJournal of Palliative Care 10(3)67-72

Ferrell B A Ferrell B R and Osterweil D 1990 Pain in the nursing homeJournal of the American Geriatric Society 38(4)409-414

Ferrell BA Ferrell BR and Rivera L1995 Pain in cognitively impairednursing home patients Journal of Pain and Symptom Management 10(8)591-598

Folstein MF Folstein SE and McHugh PR 1975 Mini-mental state apractical method of grading the cognitive state of patients for the clinicianJournal of Psychiatry Research 12(3)189-198

Glajchen M and Bookbinder M 2001 Knowledge and perceived competenceof home care nurses in pain management a national survey Journal of Painand Symptom Management 21(4)307-316

Hall-Lord M L Larsson G and Steen B 1999 Chronic pain and distressamong elderly in the community comparison of patientsrsquo experiences withenrolled nursesrsquo assessments Journal of Nursing Management 7(1)45-54

Hamilton J and Edgar L 1992 A survey examining nursesrsquo knowledge of paincontrol Journal of Pain and Symptom Management 7(1)18-26

Helme RD and Gibson SJ 1997 Pain in the elderly in TS Jensen JA Turner and Z Wiesenfeld-Hallin (eds) Progress in pain research andmanagement Proceedings of the 8th World Congress on Pain 8919-944 IASPPress Seattle

Helme RD Katz B Gibson SJ Bradbeer M Farrell M Neufeld M andCorran T 1996 Multidisciplinary pain clinics for older people do they have arole Clinics in Geriatric Medicine 12(3)563-82

Herr K A and Mobily P R 1991 Complexities of pain assessment in theelderly clinical considerations Journal of Gerontological Nursing 17(4)12-19

Herr KA Mobily PR Kohout F and Wagenaar D 1998 Evaluation of theFaces Pain Scale for use with the elderly Clinical Journal of Pain 14(1)29-38

Herr KA Spratt K Mobily PR and Richardson G 2004 Pain assessment inolder adults Clinical Journal of Pain 20(4)207-219

Jakobsson U Hallberg IR and Westergen A 2003 Pain management inelderly persons who require assistance with activities of daily living acomparison of those living at home with those in special accommodationsEuropean Journal of Pain 8(4)335-344

Katsma DL and Souza CH 2000 Elderly pain assessment and painmanagement knowledge of long-term care nurses Pain Management Nursing1(3)88-95

Kee C C and Epps C D 2001 Pain management practices of nurses caringfor older patients with osteoarthritis Western Journal of Nursing Research23(2)195-210

Laborde E B and Texidor M S 1996 Knowledge and attitudes towardchronic pain management among home health care nurses Home Health CareManagement Practice 9(1)73-77

Landsbury G 2000 Chronic pain management A qualitative study of elderlypeoplersquos preferred coping strategies and barriers to management Disability andRehabilitiation 22(1-2)2-14

Lasch KE 2000 Culture pain and culturally sensitive pain care PainManagement Nursing 1(3)Suppl1 pp16-22

Lichtenstein MJ Dhanda R Cornell JE Escalante A and Hazuda HP1998 Disaggregating pain and its effect on physical functional limitationsJournal of Gerontology SeriesA Biological Sciences and Medical Sciences53(5)M361-M371

Lin Y and Taylor AG 1999Effects of therapeutic touch in reducing pain andanxiety in an elderly population Integrative Medicine 1(4)155-162

McCaffery M 1968 Nursing Practice Theories Related to Cognition BodilyPain and Man-environment Interactions Los Angeles University of California

McCaffery M and Pasero C 1999 Pain Clinical Manual (2nd ed) St Louis Mosby

McCaffrey R and Freeman E 2003 Effect of music on chronic osteoarthritispain in older people Journal of Advanced Nursing 44(5)517-524

Maumlntyselka P Hartikainen S Louhivuori-Laako K and Sulkava R 2004Effects of dementia on perceived daily pain in home-dwelling elderly people Apopulation-based study Age and Ageing 33(5)496-499

Miaskowski C 2000 The impact of age on a patientrsquos perception of pain andways it can be managed Pain Management Nursing 1(3)2-7

Mobily P Herr K Clark MK and Wallace RB 1994 An epidemiologicalanalysis of pain in the elderly the Iowa 65+ rural health study Journal of Agingand Health 6(2)139-154

Muonio P 2004 Pain control in the home what have we learned HomeHealthcare Nurse 22(3)1-7

Pitkala KH Strandberg TE and Tilvis RS 2002 Management ofnonmalignant pain in home-dwelling older people a population-based surveyJournal of the American Geriatrics Society 50(11)1861-1865

Carrington Reid M Williams CS Concato J Tinetti ME and Gill TM2003 Depressive symptoms as a risk factor for disabling back pain in thecommunity-dwelling older person Journal of the American Geriatrics Society51(12)1710-1717

Ross MM and Crook J 1998 Elderly recipients of home nursing servicespain disability and functional competence Journal of Advanced Nursing27(6)1117-1126 Roy R and Thomas M 1987 Elderly persons with andwithout pain a comparative study Clinical Journal of Pain 3(22)102-106

Ruzicka SA 1998 Pain beliefs what do elders believe Journal of HolisticNursing 16(3)369-382

Scudds RJ and Robertson JM 2000 Pain factors associated with physicaldisability in a sample of community-dwelling senior citizens Journal ofGerontology 55A(7)M393-M399

Taylor LJ and Herr K 2003 Pain intensity assessment a comparison ofselected pain intensity scales for use in cognitively intact and cognitivelyimpaired African American older adults Pain Management Nursing 4(2)87-95

Toumlrnkvist L Gardulf A and Strender L 1998 The opinions of district nursesregarding the knowledge management and documentation of patients withchronic pain Scandinavian Journal of Caring Sciences 12(3)146-153

Toumlrnkvist L Gardulf A and Strender L E 2003 Effects of lsquopain-advisersrsquodistrict nursesrsquo opinions regarding their own knowledge management anddocumentation of patients in chronic pain Scandinavian Journal of CaringSciences 17(4)332-338


SCHOLARLY PAPER

38

Tse M Pun S and Benzie I 2005 Pain relief strategies used by older people with chronic pain an exploratory survey for planning patient-centredintervention Journal of Clinical Nursing 14(3)315-320

Varela-Burstein E and Miller PA 2003 Is chronic pain a risk factor for falls among community dwelling elders Topics in Geriatric Rehabilitation19(2)145-159

Walker J M Akinsanya JA Davis BD and Marcer D 1990 Nursingmanagement of elderly patients with pain in the community study andrecommendations Journal of Advanced Nursing 15(10)1154-1161

Watt-Watson JH 1987 Nursesrsquo knowledge of pain issues a survey Journal ofPain and Symptom Management 2(4)207-211

Weinstein S M Laux L F Thornby J I Lorimor R J Hill C S Jr ThorpeD M and Merrill J M 2000 Physiciansrsquo attitudes toward pain and the use ofopioid analgesics results of a survey from the Texas Cancer Pain InitiativeSouthern Medical Journal 93(5)479-487

Weissman D Griffie J Muchka S and Matson S 2000 Building aninstitutional commitment to pain management in long-term care facilities Journal

of Pain and Symptom Management 20(1)35-43

Yates P Dewar AL and Fentiman B 1995 Pain the views of elderly peopleliving in long-term residential care settings Journal of Advanced Nursing21(4)667-674

ABSTRACT

ObjectiveTo highlight the registration issues for nurses who

wish to practice nationally particularly those practicingwithin the telehealth sector

DesignAs part of a national clinical research study

applications were made to every state and territory for mutual recognition of nursing registration and fee waiver for telenursing cross boarder practice for aperiod of three years These processes are describedusing a case study approach

OutcomeThe aim of this case study was to achieve

registration in every state and territory of Australiawithout paying multiple fees by using mutualrecognition provisions and the cross-border fee waiverpolicy of the nurse regulatory authorities in order topractice telenursing

ResultsMutual recognition and fee waiver for cross-border

practice was granted unconditionally in two statesVictoria (Vic) and Tasmania (Tas) and one territorythe Northern Territory (NT) The remainder of the Australian states and territories would only grant temporary registration for the period of theproject or not at all due to policy restrictions or nurse regulatory authority (NRA) Board decisions

As a consequence of gaining fee waiver the annual cost

of registration was a maximum of $145 per annum as

opposed to the potential $959 for initial registration

and $625 for annual renewal

Conclusions

Having eight individual nurses Acts and NRAs for a

population of 265000 nurses would clearly indicate a

case for over regulation in this country The structure

of regulation of nursing in Australia is a barrier to the

changing and evolving role of nurses in the 21st

century and a significant factor when considering

workforce planning

Acknowledgements

The Chronic Heart Failure Assistance by Telephone

(CHAT) study is a National Health and Medical

Research Council (NHMRC) funded project of

the Department of Epidemiology and Preventative

Medicine Monash University Victoria Australia

Ms Robyn Clark is a PhD scholar supported by the

National Institute of Clinical Studies and the National

Heart Foundation of Australia We wish to thank

the following nursing leaders for their counsel and

support Judi Brown NBSA Sheryle Pike Nurses

Board of South Australia and Lyn LeBlanc former

CEO Australian Nursing and Midwifery Council

(ANMC) We thank the CHAT nurses Andrea Nangle

and Marilyn Black for their support and contribution

SCHOLARLY PAPER

39

Robyn A Clark RM Dip ApplScI BN Med FRCNA (LifeMember ACCCN) PhD scholar supported by the NationalInstitute of Clinical Studies and the National Heart Foundationof Australia University of South Australia Adelaide Australia

robynclarkunisaeduau

Julie Yallop NZRN Senior Research Fellow Department ofEpidemiology and Preventative Medicine Monash UniversityVictoria Australia

Di Wickett RN Dip ApplSci BN (Edu) MN ( Adv Prac)MRCNA (Life Member SAORN) PhD scholar University ofAdelaide Manager Registrations and Investigations NursesBoard of South Australia Australia

Professor Henry Krum PhD FRACP Department ofEpidemiology and Preventative Medicine Monash UniversityVictoria Australia

Professor Andrew Tonkin MBBS MD FRACP Epidemiology andPreventative Medicine Monash University Victoria Australia

Professor Simon Stewart PhD FCSA Chair of CardiovascularNursing Nursing and Midwifery University of South AustraliaAdelaide Australia


NURSING SANS FRONTIERES A THREE YEAR CASE STUDY OF MULTI-STATE REGISTRATION TO SUPPORT NURSING PRACTICE USINGINFORMATION TECHNOLOGY

Key words national registration telenursing nursing regulation



INTRODUCTION

The regulatory structure of nursing in Australia is a barrier to the changing and evolving role ofnurses in this new millennium (Bryant 2001

Kjervik 1997 Simpson 1997) In an age where travel and technology have been normalised into practice weare rapidly moving to a time when not only national but global nursing registration will be required Nurseregulatory authorities (NRAs) throughout the world needto be able to respond to the lsquovirtualrsquo location of nurses asthe environment and the way in which nurses practicechanges (Styles and Arrara 1997)

21st Century nursingEmerging 21st century nursing roles which require

national or multi-state registration include defence nurses nurses of the Royal Flying Doctor Service retrievalnurses transplant coordinators nurse lecturers with on-linecourses nurses who teleconference tele-nurses or callcentre nurses nurses who work for an agency which isnationally based and overseas nurses who wish to workand holiday around Australia (Bryant 2001)

The incidence and use of e-health is increasinghowever barriers such as lsquoturf issuesrsquo fee for lsquovirtualrsquoconsultations and a degree of technophobia amongstregulators have prevented wide spread adaptation(Mitchell 1998)

As an example telenursing was defined by theAustralian Nursing and Midwifery Council in 2003 asnursing using information technology Telenursing is an evolving specialty and has the potential to recruit and retain specialist nurses who may not wish to work within the structure of mainstream healthcare(Queensland Health 1999) Due to its nature telenursingcan seamlessly transcend state borders and has the abilityto reduce the duplicity that plagues our state basedhealthcare systems (Preston et al 1992 Whitten 2000Whitten et al 2000)

Federal and state governments have indicated interestin the implementation of a National Health ServiceDirect (NHS Direct) style telephone support service intothe Australian health care system (Sheffield Medical CareResearch Unit 2000) NHS Direct operates a 24-hournurse advice and health information service providingconfidential information on what to do if you or yourfamily are feeling ill particular health conditions localhealth care services such as doctors dentists or late nightopening pharmacies and self help and supportorganisations The telephone service is available inEngland and Wales and a similar service called NHS24was introduced in Scotland in 2002

Many Australian states already have versions of NHS Direct out-of-hours telephone triage systems or telemonitoring services which are supported by nurses (Fatovich et al 1998 Celler et al 1999 Lattimer et al 1998 Turner et al 2002)

Telenursing systems have been easily adapted into theUnited Kingdomrsquos (UK) health care system as nurses inthe UK are registered under one comprehensive nationalprocess for England Scotland and Wales and thereforecross-border or multi-state practice regulations are irrelevant

Current medical nursing and legal literature aboundswith discussion about the square peg of practice usinginformation technology fitting the round hole of healthcare regulation (Joel 1999) This is particularly evident in the telehealth telemedicine and e-health literature In the USA and Canada health care workers share similardilemmas with regard to cross-border or multi-statepractice because like Australia these countries also havestate based or province based health professional regulation(Creal 1996 Gassert 2000) Problems associated withmulti-state practice ie multiple registration fees andvariances in licensure to practice are complex Howeverthese issues need to be addressed if nursing is to takeadvantage of current and future technologies as thesemodes of health care promise to increase accessibility andequitable delivery of quality care to vulnerable andunderserved populations

The Chronic Heart Failure Assistance by Telephone(CHAT) study

The Chronic Heart Failure Assistance by Telephone(CHAT) study is a National Health and Medical ResearchCouncil (NHMRC) funded project which involves nurse-led telephone support for patients with heart failure livingin metropolitan and in particular rural and remote areasAlthough this telenursing system is being tested withheart failure patients it has the potential to be adapted forall chronic diseases This type of telephone support bringsspecialist nursing care to the frail and elderly in theirhomes normally outside of the radar of recommendedheart failure care such as home visiting services

For the past three years the CHAT study has been usedas a vehicle to test whether the nurse regulatoryauthorities (NRAs) regulation of nursing in Australiasupports a model of nursing care which requires usingmutual recognition provisions and cross-border fee waiverto enable cost effective national telenursing practice

DEFINITIONSFor the purposes of this study the following definitions

have been used

Mutual RecognitionNurses and midwives who have current authority to

practise as a registered nurse registered midwife orenrolled nurse in one state or territory of Australia mayapply for recognition in another state or territory underthe Mutual Recognition Act 1992

SCHOLARLY PAPER

40


Nurses and midwives who have current authority topractise as a registered nurse registered midwife orenrolled nurse in New Zealand may also apply forrecognition in an Australian state or territory under theTrans Tasman Mutual Recognition Act 1997 Under theprovisions of the Mutual Recognition Act 1992 a personwho has a current authority to practise in one state orterritory is eligible to be registered and to carry on that equivalent occupation in a second state or territoryThis right may be exercised provided that certainconditions including lodgement of a StatutoryDeclaration (written notice) are met Mutual recognitionprovides an additional and alternative avenue forobtaining registration or enrolment for nurses in AustraliaApplicants have the choice of applying for registration orenrolment under the Mutual Recognition Act 1992 or theindividual nurses and midwives Act in the jurisdiction inwhich they wish to practice

Cross-border Fee WaiverIn a country as large as Australia nurses may at times

be required to travel across state and territory borders toprovide a nursing service In the interests of reducing thefinancial burden on those nurses who are required toregister in more than one state or territory all nurseregulatory authorities in Australia now have the ability in certain circumstances to consider waiving the fees or exempt an individual from the requirement to pay a fee The criteria for waiver of fees for registration orenrolment are

bull holding current registration or enrolment as a nursemidwifemental health nursenurse practitioner inanother Australian state or territory and

bull employment as a nursemidwifemental health nursenurse practitioner in another Australian state orterritory and

bull required as a condition of your employment to crossa state or territory border to practise nursing in thisstate for short periods at irregular intervals during aperiod of time which extends over one month

This principle exempts a nurse from the obligation topay the registration or enrolment and practice fees(Nurses Board of South Australia 2005)

Telenursing policyTelenursing occurs when nurses meet the health needs

of clients through assessment triage and provision ofinformation using information and communicationtechnology and web based systems Nurses practisingtelenursing are generally required to be registered nursesEnrolled nurses involved in telenursing are supervised bya registered nurse In Victoria a registered nurse is knownas registered nurse (Division 1) and an enrolled nurse as registered nurse (Division 2) Nurses practisingtelenursing are responsible for ensuring that their nursingskills and expertise remain current for their practise

Nurses who are practising telenursing in Australia areexpected to practise within the framework of theAustralian Nursing and Midwifery Council (ANMC)National Competency Standards for Registered Nursesthe ANMC Code of Professional Conduct for Nurses inAustralia Code of Ethics for Nurses in Australia andother relevant professional standards (ANMC 2003)

METHODOver the three years in which this case study took

place the nurses in the CHAT study documentedrecorded and filed all correspondence phone calls and emails related to the aim of achieving nationalregistration The application process also involved frequentconsultation with experts in the field of nursing regulationThe outcomes of those phone calls and meetings were alsorecorded The following is a report of these accounts

Results

Year One In the first year of the project representatives of the

CHAT studyrsquos nursing team met with the Nurses Board of South Australia (NBSA) to introduce the project andinform the Board of the intention to practice nationallyfrom a call centre located in the South Australian Branchof the National Heart Foundation of Australia The teamalso sort advice on how to apply for national registrationthe case for national registration as a requirement of theCHAT study was sent to all state and territory boards andthe ANMC

After five months replies were received from allrecipients The NRAs stated unanimously that theysupported the newly signed ANMC National TelenursingPolicy Consequently seven sets of application forms for mutual recognition and cross-border fee waiver wereforwarded to each of the NRArsquos of each of Australiarsquos five state and two territories (excluding South Australia)Without fee waiver the annual cost for nationalregistration for each CHAT registered nurse (RN) wouldhave been $959 initially (home state annual practisingfee plus registration by mutual recognition in every otherstate and territory) then $625 for re-registration annually(see table 1)

The initial applications for mutual recognition requiredverification of identity current registration and a statutorydeclaration witnessed by a Justice of the Peace (JP) Thisverification process took one to two hours and involved21 separate co-signings with the JP The application formswere then posted to the states and territories for processingTable 2 is a summary of the response from each NRA forYear 1 2003

Following the initial application and due to the differences in policies between jurisdictions additional information was requested from several states

SCHOLARLY PAPER

41


For example in Queensland in accordance with theprovisions of the amendments to the Nurses Act 1992(QLD) it was determined that where nurses are employedand registered in another jurisdiction and as part of theiremployment position and role are required to cross theborder into Queensland to provide nursing care theBoard would consider applications on an individual basissubject to the following requirements being met

1 A nurse must be currently registered with the nurseregulatory authority in the jurisdiction in which thenurse is employed by a health facility

2 The terms of employment require the nurse to crossinto Queensland to provide nursing care for a periodof time but the majority of time is undertaken in thejurisdiction in which the employer is located

3 The nurse must apply to the Queensland NursingCouncil for fees to be waived for initial registrationand for annual renewal as appropriate

As a result of the Queensland Nursing Act 1992amendments the following additional documentaryevidence was required

1 Current registration in the jurisdiction in which thenurse is employed

2 A formal letter from the employer which identifiesthe nurse advises the role of the nurse therequirements of the position and confirms that as partof the nursersquos employment the nurse must providenursing care in Queensland This letter needed toinclude the number of hours each week the nursewas required to cross into Queensland to providecare and the days of employment spent in thejurisdiction where the employer is located

For the waiving of fees to be considered thisinformation was required at the time of initial applicationand annually thereafter The CHAT study chief investigatorverified in writing that the study required cross-borderpractice to care for Queensland participants in the CHATprogram and that the time to be spent with Queenslandheart failure patients was not longer than that spentpracticing in any other state

By the time the processes and correspondence fornational registration were completed for the initial year (2003) it was time to begin renewing each stateregistration for the second year of the study 2004 (seetable 3)

Year Two In year two the CHAT nursing team had to address the

issues which arose as a consequence of each state havinga different date for renewal Table 3 demonstrates howthree of the states and territories required renewal beforethe annual renewal was due in the home state Withoutguidelines a decision was made to proceed in the secondyear by simply repeating the process for the first year

SCHOLARLY PAPER

42

Table 1 CHAT Study Telenursing National Registration Costs

States Once only Annual

1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory

Mutual Recognitioninitial application for RN (Div1) (based upon2006 fee structure)

Annual renewal RN(Div1) (based upon2005 fee structure)

Table 2 CHAT Study Telenursing National Registration Status

StateTerritory

Registration status

Recognition of telenursing policy

Source Australian nursing and midwifery regulatory authorities (accessed March 2006)Nursing Board of Tasmania wwwnursingboardtasorgauNurses Board of the ACT wwwnursesboardactgovauNurses and Midwives Board of NSW wwwnmbnswgovauNursing and Midwifery Board of the Northern Territory wwwntgovauNurses Board of South Australia wwwnursesboardsagovauNursing Board of Victoria wwwnbvorgauNurses Board of Western Australia wwwnbwaorgauQueensland Nursing Council wwwqncqldgovau

Nursing Board of Tasmania wwwnursingboardtasorgauNurses Board of the ACT wwwnursesboardactgovauNurses and Midwives Board of NSW wwwnmbnswgovauNursing and Midwifery Board of the Northern Territory wwwntgovauNurses Board of South Australia wwwnursesboardsagovauNursing Board of Victoria wwwnbvorgauNurses Board of Western Australia wwwnbwaorgauQueensland Nursing Council wwwqncqldgovau

Cross-borderfee waivergranted

States

1 NBSA Full Yes NA

2 QNC Full Yes QNCConditions

3 VIC Full Yes Yes

4 NSW Temp Yes NSWConditions

5 TAS Full Yes Yes

6 WA Temporary Yes Temporary

Territories

7 NT Full Yes Yes

8 ACT Full Yes No


Registrations which needed to be renewed before ourhome-state renewal date were paid and a refund for feewaiver sort once our annual practicing certificates wererenewed Additional information was provided to the QNCas before

Also in the second year a meeting took place with keymembers of the Nurses Board of South Australia toreport on progress A significant break through at thismeeting was that the CHAT nursing team were advisedthat there was flexibility within the re-registrationprocess to allow the team to register early each year (inJune rather than August 31st) This concession enabledthe nurses to be re-registered each year before renewalsin the majority of other states became due (see table 3)

Of interest at this point was a request to forward adiscussion paper to the ANMC on the experiences of theCHAT team in accessing mutual recognition provisions forregistration and re-registration and in seeking cross-borderfee waiver The discussion paper was requested to informan agenda item for a national meeting of NRAs Thediscussion paper addressed the registration issues theteam had encountered and made recommendations basedon the experiences in the first two years of the study

The ANMC is the national coordinating body for theNRAs Its Board is made up of one representative fromeach state and territory NRA and two public members(an accountant and a lawyer) The ANMC is the forumwhere regulatory issues are discussed and policy andposition statements developed One of the purposes ofthe ANMC is to assist national consistency in nurseregulation To date how successful the ANMC has beenin achieving these aims is arguable

Year ThreeBy year three (2005-2006) mutual recognition renewal

and cross-border fee waiver had evolved to a smootherand slightly less time consuming process The method ofapplication had been refined to completion of the standardrenewal forms and competency statements for each stateand territory with lsquoFee Waiverrsquo written as a reminder over the section where payment details were indicated

SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

WA Last day of month of birth

3 statesdue beforehome staterenewal

Table 3 Australian State and Territory Annual NursingRegistration renewal due dates (2005)

The applications were forwarded collectively along with a covering letter reminding the NRA administrativeprocessors about the CHAT study and giving notificationthat the conclusion date for the project had been set forSeptember 2006

Annually as a baseline the study nurses renewed paid full registration fees and completed competencystatements in their home state (SA)

As a result of the national applications mutualrecognition and fee waiver for cross-border practice wasgranted unconditionally in two states Victoria (Vic) andTasmania (Tas) and the Northern Territory (NT) (seetable 2) The remainder of Australian states andterritories would only grant mutual recognition ortemporary registration for the period of the project due topolicy restrictions or NRA Board decisions TheAustralian Capital Territory (ACT) reported that it didnot have legislation permitting fee waiver (Nurses Boardof Australian Capital Territory Nurses Act 1988)Although we were given mutual recognition in ACTwe were required to pay full registration each year ACTwas the only state where any concession for fee payment did not occur Queensland granted mutual recognition and conditional fee waiver for cross border practice(Queensland Nursing Council 2003) NSW and WAgranted temporary registration and fee waiver for thepurpose and duration of the project only NSW has sinceimplemented policy requirements similar to those inQueensland to allow fee waiver with similaradministrative requirements (Nurses and Midwives Boardof New South Wales 2005)

The processing time for the registration applicationsvaried between states and territories The NT acceptedand processed the application within three weeksConversely in Western Australia the final acceptancewas completed after nine months from initial application

CostApproval of fee waiver reduced the annual cost of

registration from $625 (initial cost $959) to a maximumof $145 The $145 comprises the South Australian annualrenewal fee ($100) and the annual renewal fee ACTwhich could not fee waiver (see table 1)

DISCUSSIONAll Australian state nursing regulatory authorities

have co-signed a telenursing policy agreement through collaboration with the ANMC The actualimplementation of this policy has been inconsistent due to variances in interpretation (Australian Nursingand Midwifery Council 2003) As a consequence the aim of this case study which was to achieve national registration with full fee waiver in every state and territory of Australia was not achieved

What was achieved was mutual recognition and fee waiverfor cross-border practice granted unconditionally in twostates and one territory reflecting only a 375unconditional support rate for the policies which facilitatethe practice of national telenursing

Currently in Australia there are eight nurses Acts andeight NRAs for a population of 260075 registered and enrolled nurses (Australian Institute of Health andWelfare 2002) This according to Bryant (2001) wouldseem to be a clear case for over-regulation Furthermorethe differences in NRA policy and legislation implementationin Australia add to this over-regulation resulting in the delayscosts and frustrations experienced by the research team

The study experience has confirmed firstly thatmutual recognition has addressed national registrationissues in part however there are still significant sectionsof the various Acts that are inconsistent (Bryant 2001)And secondly it is no longer logical for nurses who are anational resource to be regulated on a state or territorybasis subject to the vagaries of statersquos rights and theindividual whims of politicians and nursing leaders at alocal level (Bryant 2001)

There is also an unexplained inequity in fee structurewithin Australia The cost range of annual initialregistration was from $60 (NSW) to $200 (TAS) with a median of $129 (QLD) The highest fee for annualregistration renewal was charged in Tasmania and Victoria($120) and the lowest level in NSW ($50) with a medianfee of $90 (WA) The nurses Acts provide the legislativepower to charge a fee for registration however the fees andwaiving of fees are based on the individual NRA policies

Although this paper is a report of a nationalregistration experience from the point of view of nursingit must be noted that regulation of medical practitionersand indeed all eligible health professions in this countryare state based and it would be reasonable to assume thatthe experiences found in this case study would begeneralisable across all health care professions

National registration for nurses is the optimal methodof achieving national consistency There are other lessradical options which do not involve the conceding ofpowers by states territories and the federal governmentsuch as the call for a national template for the regulationof health professionals and the amendment of all relevantlegislation and policy within an agreed time frame(Bryant 2001) As a result of this study the followingrecommendations are made

bull The process for streamlining and facilitating nationalregistration should become a priority for nursing andmidwifery

bull A single date for annual registration should beestablished nationally with pro-rata costs forregistration beyond that date

bull A national on-line registration system and feestructure administered from each state should beestablished which automatically includes nationalregistration and

bull A single consistent application and annual renewalprocess should apply with nationally standardisedapplication forms

Centralised national registration will not only savemoney for the nurse but valuable government resourcesCentral national registration or single payment would alsosupport and encourage health services that are nationallybased as it would facilitate the increasing movement ofnurses across state and territory borders without penalty

CONCLUSIONThe CHAT Study has enrolled over three hundred and

fifty chronic heart failure (CHF) patients who aresupported by a team of specialist cardiac nurses Thepatients are located in metropolitan rural and remoteareas of every state and territory of Australia Thistelenursing project represents a potentially cost-effectiveand accessible model for the Australian health system in caring for CHF patients Furthermore a telephonebasedtelemedicine system enables a limited resourcenamely nurses to monitor and support a larger than usualcaseload of patients The aim of the CHAT interventionwas to support general practitioners in their provision ofcare to CHF patients by providing evidence basedtelephone support to keep this generally frail and elderlygroup out of hospital and at home longer

Without national registration the CHAT nationaltelenursing research study would not have been possiblelegally and would have been severely limited financially

The current cost of national registration (without feewaiver) has the potential to limit growth within practiceareas that require cross border nursing care and is asignificant burden to employees andor employers

Telehealth and telenursing practice is developing at arapid rate It is time to create an Australian nurse (asopposed to a Victorian or South Australian nurse etc) whopractices without boarders (sans frontiegraveres) regulated byone authority with one single piece of legislation and onefee structure

REFERENCESAustralian Institute of Health and Welfare 2002 Nursing Labour Force 2001AIHW Cat No HWL 29 Canberra

Australian Nursing and Midwifery Council 2003 Guidelines on TelenursinghttpwwwanmcorgauwebsitePolicyDownloadsGuidelines20on20telenursingpdf (accessed Jan 2005)

Bryant R 2001 The regulation of nursing in Australia a comparative analysisJournal of Law and Medicine 9(1)41-57

Celler BC Lovell NH and Chan DK 1999 The potential impact of hometelecare on clinical practice Medical Journal of Australia 171(10)518-521


SCHOLARLY PAPER

44


SCHOLARLY PAPER

45

Creal D 1996 Telenursing the regulatory implications Issues 17(3)8-9

Fatovich DM Jacobs IG McCance JP Sidney KL and White R J 1998Emergency department telephone advice Medical Journal of Australia169(3)143-146

Gassert CA 2000 Telehealth a challenge to the regulation of multistate practicePolicy Politics and Nursing Practice 1(2)85-92

Joel LA 1999 Viewpoint multistate licensure American Journal of Nursing99(1)9

Kjervik DK 1997 Telenursing-licensure and communication challenges Journalof Professional Nursing 13(2)65

Lattimer VS George S Thompson F Thomas E Mullee M Turnbull J Smith H Moore M Bond H and Glasper A 1998 Safety and effectivenessof nurse telephone consultation in out of hours primary care randomizedcontrolled trial British Medical Journal 317(7165)1054-1059

Mitchell JG 1998 The telemedicine industry in Australia from fragmentation tointegration Canberra Department of Industry Science and Tourism

Nurses and Midwives Board of New South Wales 2005 Cross-border practiceand fee waiver httpwwwnmbnswgovauwaivfeeshtm (accessed June 2005)

Nurses Board of Australian Capital Territory 1988 Nurse Act 1988 (ACT)httpweb2govmbcalawsstatutesccsmr040ephp (accessed June 2005)

Nurses Board of South Australia 2005 Cross-border fee waiver principlehttpwwwnursesboardsagovaureg_cbnphtml (accessed June 2005)

Preston JF Brown W and Hartley B 1992 Using telemedicine to improvehealthcare in distant areas Hosp Community Psychiatry 43(1)25-32

Queensland Health 1999 Nursing and recruitment and retention taskforce reportBrisbane Government of Queensland

Queensland Nursing Council 2003 Fee waiver policy for registrationhttpwwwqncqldgovauuploadpdfsqnc_policiesRegistraion_Policypdf(accessed June 2005)

Sheffield Medical Care Research Unit 2000 Evaluation of NHS Direct firstwave sites Second interim report to the Department of Health University ofSheffield httpwwwshefacuk~scharrmcrureportshtm (accessed June 2005)

Simpson RL 1997 State Regulation in a world of lsquoboundary-lessrsquo technologyNursing Management 28(2)22

Styles MM and Arrara F 1997 ICN on Regulation toward a 21st CenturyModel Geneva International Council of Nurses

Turner V F Bentley PJ Hodgson SA Collard RA Rabune C and Wilson AJ2002 Telephone triage in Western Australia Medical Journal of Australia176(3)100-103

Whitten P 2000 What do we know about telemedicine and what will it mean forprimary care physicians Western Journal of Medicine 173(3)174-175

Whitten P Kingsley C and Grigsby J 2000 Results of a meta-analysis of costbenefit research is this a question worth asking Journal of Telemedicine andTelecare 6 (Suppl 1)4-6

FROM THE EDITOR

GUEST EDITORIAL

COMPETENCY AND CAPABILITY IMPERATIVE FOR NURSEPRACTITIONER EDUCATION





NURSING SANS FRONTIERES A THREE YEAR CASE STUDY OFMULTI-STATE REGISTRATION TO SUPPORT NURSING PRACTICE USINGINFORMATION TECHNOLOGY


EDITORIAL

that family friendly ward environments need to befostered supported by appropriate policies

Day and Batten having identified that cardiacrehabilitation programs have been based on research withalmost exclusively male participants investigate womenrsquosperceptions of the contribution of cardiac rehabilitation totheir recovery from a myocardial infarction UsingGlaserian grounded theory the core theme that emergedfrom their data was lsquoregaining everydaynessrsquo Theseauthors found programs did not meet the needs of allparticipants and it was apparent that one size does not fitall The final research paper from Brumley et al aimed toimprove access to clinical information for nurses anddoctors providing after hours community palliative care in a regional Australian setting They describe an actionresearch project designed to improve collation anddistribution of succinct pertinent and timely informationabout unstable palliative care patients to nurses andgeneral practitioners (GPs) involved in after hours care

Dewar reviews the nursing research literature onchronic pain in the older person living in the communityShe argues that to provide care the many parameters

of chronic pain which include physical as well as thepsycho-social impact and the effect of pain on patientsand their families must be carefully assessed Furtherthat the beliefs of the older person about pain and painmanagement are also important and not necessarilysought Our final scholarly paper by Clark et al draws onexperiences from a national clinical research study tohighlight the registration issues for nurses who wish topractice nationally particularly those practicing within thetelehealth sector The authors found that the state andterritory structure of the regulation of nursing in Australiais a barrier to the changing and evolving role of nurses in the 21st century and consider this a significant factorwhen considering workforce planning

REFERENCESAustralian Nursing and Midwifery Council 2006 National CompetencyStandards for the Registered Nurse (Standard 95) wwwanmcorgau

OrsquoBrien K 2002 Problems and potentials of complementary and alternativemedicine Internal Medicine Journal 32(4)163-164

Wilding C Muir-Cochrane E and May E 2006 Treading lightly spiritualityissues in mental health nursing International Journal of Mental HealthNursing 15(2)144-152


GUEST EDITORIAL














GUEST EDITORIAL




















RESEARCH PAPER

ABSTRACT











Acknowledgements










capability learning

INTRODUCTION






two countries















nurse practitioner


gegardnerquteduau








RESEARCH PAPER

9













Data collection





Data analysis






RESEARCH PAPER

10



















12 Title of program


14 Level of award











33 Graduate profile

4 Program delivery







6 Program content











RESEARCH PAPER

11






















These were





RESEARCH PAPER

12















DISCUSSION







RESEARCH PAPER

13















































RESEARCH PAPER

14


jcioffiuwseduau



RESEARCH PAPER

ABSTRACT













INTRODUCTION









METHOD










RESEARCH PAPER

16


Characteristic f=




































RESEARCH PAPER

17





















RESEARCH PAPER

18


























RESEARCH PAPER

19


















RESEARCH PAPER

20


ABSTRACT











INTRODUCTION







wdayucolacnz




RESEARCH PAPER




















RESEARCH PAPER

22



Restricted roles














RESEARCH PAPER

23





REFRAMING



Carrying on

Being supported




















RESEARCH PAPER

24






































RESEARCH PAPER

25























RESEARCH PAPER

26


ABSTRACT

Objective


Design

















johnfibhsorgau





RESEARCH PAPER






bull communication







bull history

















RESEARCH PAPER

28




METHOD

Objective


Design










used in this study










RESEARCH PAPER

29



LIMITATIONS




















RESEARCH PAPER

30










































RESEARCH PAPER

31


RESEARCH PAPER

32


Name

Address

Phone

UR No DOB


GP Name Phone Fax

NOK Phone

Specialist

Brief History

Primary Diagnosis

Secondary Diagnosis



Current treatment


Pain 1 Anxiety

Pain 2 Depression




Mobility [fatigue]





Patient

Carer

Last updated



SCHOLARLY PAPER

ABSTRACT




















dewarnursingubcca





SCHOLARLY PAPER

34

LITERATURE REVIEW













SCHOLARLY PAPER

35














SCHOLARLY PAPER

36













SCHOLARLY PAPER

37




















































SCHOLARLY PAPER

38









ABSTRACT













Conclusions







workforce planning

Acknowledgements















SCHOLARLY PAPER

39













INTRODUCTION















have been used



SCHOLARLY PAPER

40














Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL








GUEST EDITORIAL














GUEST EDITORIAL




















RESEARCH PAPER

ABSTRACT











Acknowledgements










capability learning

INTRODUCTION






two countries















nurse practitioner


gegardnerquteduau








RESEARCH PAPER

9













Data collection





Data analysis






RESEARCH PAPER

10



















12 Title of program


14 Level of award











33 Graduate profile

4 Program delivery







6 Program content











RESEARCH PAPER

11






















These were





RESEARCH PAPER

12















DISCUSSION







RESEARCH PAPER

13















































RESEARCH PAPER

14


jcioffiuwseduau



RESEARCH PAPER

ABSTRACT













INTRODUCTION









METHOD










RESEARCH PAPER

16


Characteristic f=




































RESEARCH PAPER

17





















RESEARCH PAPER

18


























RESEARCH PAPER

19


















RESEARCH PAPER

20


ABSTRACT











INTRODUCTION







wdayucolacnz




RESEARCH PAPER




















RESEARCH PAPER

22



Restricted roles














RESEARCH PAPER

23





REFRAMING



Carrying on

Being supported




















RESEARCH PAPER

24






































RESEARCH PAPER

25























RESEARCH PAPER

26


ABSTRACT

Objective


Design

















johnfibhsorgau





RESEARCH PAPER






bull communication







bull history

















RESEARCH PAPER

28




METHOD

Objective


Design










used in this study










RESEARCH PAPER

29



LIMITATIONS




















RESEARCH PAPER

30










































RESEARCH PAPER

31


RESEARCH PAPER

32


Name

Address

Phone

UR No DOB


GP Name Phone Fax

NOK Phone

Specialist

Brief History

Primary Diagnosis

Secondary Diagnosis



Current treatment


Pain 1 Anxiety

Pain 2 Depression




Mobility [fatigue]





Patient

Carer

Last updated



SCHOLARLY PAPER

ABSTRACT




















dewarnursingubcca





SCHOLARLY PAPER

34

LITERATURE REVIEW













SCHOLARLY PAPER

35














SCHOLARLY PAPER

36













SCHOLARLY PAPER

37




















































SCHOLARLY PAPER

38









ABSTRACT













Conclusions







workforce planning

Acknowledgements















SCHOLARLY PAPER

39













INTRODUCTION















have been used



SCHOLARLY PAPER

40














Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL








GUEST EDITORIAL




















RESEARCH PAPER

ABSTRACT











Acknowledgements










capability learning

INTRODUCTION






two countries















nurse practitioner


gegardnerquteduau








RESEARCH PAPER

9













Data collection





Data analysis






RESEARCH PAPER

10



















12 Title of program


14 Level of award











33 Graduate profile

4 Program delivery







6 Program content











RESEARCH PAPER

11






















These were





RESEARCH PAPER

12















DISCUSSION







RESEARCH PAPER

13















































RESEARCH PAPER

14


jcioffiuwseduau



RESEARCH PAPER

ABSTRACT













INTRODUCTION









METHOD










RESEARCH PAPER

16


Characteristic f=




































RESEARCH PAPER

17





















RESEARCH PAPER

18


























RESEARCH PAPER

19


















RESEARCH PAPER

20


ABSTRACT











INTRODUCTION







wdayucolacnz




RESEARCH PAPER




















RESEARCH PAPER

22



Restricted roles














RESEARCH PAPER

23





REFRAMING



Carrying on

Being supported




















RESEARCH PAPER

24






































RESEARCH PAPER

25























RESEARCH PAPER

26


ABSTRACT

Objective


Design

















johnfibhsorgau





RESEARCH PAPER






bull communication







bull history

















RESEARCH PAPER

28




METHOD

Objective


Design










used in this study










RESEARCH PAPER

29



LIMITATIONS




















RESEARCH PAPER

30










































RESEARCH PAPER

31


RESEARCH PAPER

32


Name

Address

Phone

UR No DOB


GP Name Phone Fax

NOK Phone

Specialist

Brief History

Primary Diagnosis

Secondary Diagnosis



Current treatment


Pain 1 Anxiety

Pain 2 Depression




Mobility [fatigue]





Patient

Carer

Last updated



SCHOLARLY PAPER

ABSTRACT




















dewarnursingubcca





SCHOLARLY PAPER

34

LITERATURE REVIEW













SCHOLARLY PAPER

35














SCHOLARLY PAPER

36













SCHOLARLY PAPER

37




















































SCHOLARLY PAPER

38









ABSTRACT













Conclusions







workforce planning

Acknowledgements















SCHOLARLY PAPER

39













INTRODUCTION















have been used



SCHOLARLY PAPER

40














Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL








RESEARCH PAPER

ABSTRACT











Acknowledgements










capability learning

INTRODUCTION






two countries















nurse practitioner


gegardnerquteduau








RESEARCH PAPER

9













Data collection





Data analysis






RESEARCH PAPER

10



















12 Title of program


14 Level of award











33 Graduate profile

4 Program delivery







6 Program content











RESEARCH PAPER

11






















These were





RESEARCH PAPER

12















DISCUSSION







RESEARCH PAPER

13















































RESEARCH PAPER

14


jcioffiuwseduau



RESEARCH PAPER

ABSTRACT













INTRODUCTION









METHOD










RESEARCH PAPER

16


Characteristic f=




































RESEARCH PAPER

17





















RESEARCH PAPER

18


























RESEARCH PAPER

19


















RESEARCH PAPER

20


ABSTRACT











INTRODUCTION







wdayucolacnz




RESEARCH PAPER




















RESEARCH PAPER

22



Restricted roles














RESEARCH PAPER

23





REFRAMING



Carrying on

Being supported




















RESEARCH PAPER

24






































RESEARCH PAPER

25























RESEARCH PAPER

26


ABSTRACT

Objective


Design

















johnfibhsorgau





RESEARCH PAPER






bull communication







bull history

















RESEARCH PAPER

28




METHOD

Objective


Design










used in this study










RESEARCH PAPER

29



LIMITATIONS




















RESEARCH PAPER

30










































RESEARCH PAPER

31


RESEARCH PAPER

32


Name

Address

Phone

UR No DOB


GP Name Phone Fax

NOK Phone

Specialist

Brief History

Primary Diagnosis

Secondary Diagnosis



Current treatment


Pain 1 Anxiety

Pain 2 Depression




Mobility [fatigue]





Patient

Carer

Last updated



SCHOLARLY PAPER

ABSTRACT




















dewarnursingubcca





SCHOLARLY PAPER

34

LITERATURE REVIEW













SCHOLARLY PAPER

35














SCHOLARLY PAPER

36













SCHOLARLY PAPER

37




















































SCHOLARLY PAPER

38









ABSTRACT













Conclusions







workforce planning

Acknowledgements















SCHOLARLY PAPER

39













INTRODUCTION















have been used



SCHOLARLY PAPER

40














Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL








RESEARCH PAPER

9













Data collection





Data analysis






RESEARCH PAPER

10



















12 Title of program


14 Level of award











33 Graduate profile

4 Program delivery







6 Program content











RESEARCH PAPER

11






















These were





RESEARCH PAPER

12















DISCUSSION







RESEARCH PAPER

13















































RESEARCH PAPER

14


jcioffiuwseduau



RESEARCH PAPER

ABSTRACT













INTRODUCTION









METHOD










RESEARCH PAPER

16


Characteristic f=




































RESEARCH PAPER

17





















RESEARCH PAPER

18


























RESEARCH PAPER

19


















RESEARCH PAPER

20


ABSTRACT











INTRODUCTION







wdayucolacnz




RESEARCH PAPER




















RESEARCH PAPER

22



Restricted roles














RESEARCH PAPER

23





REFRAMING



Carrying on

Being supported




















RESEARCH PAPER

24






































RESEARCH PAPER

25























RESEARCH PAPER

26


ABSTRACT

Objective


Design

















johnfibhsorgau





RESEARCH PAPER






bull communication







bull history

















RESEARCH PAPER

28




METHOD

Objective


Design










used in this study










RESEARCH PAPER

29



LIMITATIONS




















RESEARCH PAPER

30










































RESEARCH PAPER

31


RESEARCH PAPER

32


Name

Address

Phone

UR No DOB


GP Name Phone Fax

NOK Phone

Specialist

Brief History

Primary Diagnosis

Secondary Diagnosis



Current treatment


Pain 1 Anxiety

Pain 2 Depression




Mobility [fatigue]





Patient

Carer

Last updated



SCHOLARLY PAPER

ABSTRACT




















dewarnursingubcca





SCHOLARLY PAPER

34

LITERATURE REVIEW













SCHOLARLY PAPER

35














SCHOLARLY PAPER

36













SCHOLARLY PAPER

37




















































SCHOLARLY PAPER

38









ABSTRACT













Conclusions







workforce planning

Acknowledgements















SCHOLARLY PAPER

39













INTRODUCTION















have been used



SCHOLARLY PAPER

40














Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL








RESEARCH PAPER

10



















12 Title of program


14 Level of award











33 Graduate profile

4 Program delivery







6 Program content











RESEARCH PAPER

11






















These were





RESEARCH PAPER

12















DISCUSSION







RESEARCH PAPER

13















































RESEARCH PAPER

14


jcioffiuwseduau



RESEARCH PAPER

ABSTRACT













INTRODUCTION









METHOD










RESEARCH PAPER

16


Characteristic f=




































RESEARCH PAPER

17





















RESEARCH PAPER

18


























RESEARCH PAPER

19


















RESEARCH PAPER

20


ABSTRACT











INTRODUCTION







wdayucolacnz




RESEARCH PAPER




















RESEARCH PAPER

22



Restricted roles














RESEARCH PAPER

23





REFRAMING



Carrying on

Being supported




















RESEARCH PAPER

24






































RESEARCH PAPER

25























RESEARCH PAPER

26


ABSTRACT

Objective


Design

















johnfibhsorgau





RESEARCH PAPER






bull communication







bull history

















RESEARCH PAPER

28




METHOD

Objective


Design










used in this study










RESEARCH PAPER

29



LIMITATIONS




















RESEARCH PAPER

30










































RESEARCH PAPER

31


RESEARCH PAPER

32


Name

Address

Phone

UR No DOB


GP Name Phone Fax

NOK Phone

Specialist

Brief History

Primary Diagnosis

Secondary Diagnosis



Current treatment


Pain 1 Anxiety

Pain 2 Depression




Mobility [fatigue]





Patient

Carer

Last updated



SCHOLARLY PAPER

ABSTRACT




















dewarnursingubcca





SCHOLARLY PAPER

34

LITERATURE REVIEW













SCHOLARLY PAPER

35














SCHOLARLY PAPER

36













SCHOLARLY PAPER

37




















































SCHOLARLY PAPER

38









ABSTRACT













Conclusions







workforce planning

Acknowledgements















SCHOLARLY PAPER

39













INTRODUCTION















have been used



SCHOLARLY PAPER

40














Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL








RESEARCH PAPER

11






















These were





RESEARCH PAPER

12















DISCUSSION







RESEARCH PAPER

13















































RESEARCH PAPER

14


jcioffiuwseduau



RESEARCH PAPER

ABSTRACT













INTRODUCTION









METHOD










RESEARCH PAPER

16


Characteristic f=




































RESEARCH PAPER

17





















RESEARCH PAPER

18


























RESEARCH PAPER

19


















RESEARCH PAPER

20


ABSTRACT











INTRODUCTION







wdayucolacnz




RESEARCH PAPER




















RESEARCH PAPER

22



Restricted roles














RESEARCH PAPER

23





REFRAMING



Carrying on

Being supported




















RESEARCH PAPER

24






































RESEARCH PAPER

25























RESEARCH PAPER

26


ABSTRACT

Objective


Design

















johnfibhsorgau





RESEARCH PAPER






bull communication







bull history

















RESEARCH PAPER

28




METHOD

Objective


Design










used in this study










RESEARCH PAPER

29



LIMITATIONS




















RESEARCH PAPER

30










































RESEARCH PAPER

31


RESEARCH PAPER

32


Name

Address

Phone

UR No DOB


GP Name Phone Fax

NOK Phone

Specialist

Brief History

Primary Diagnosis

Secondary Diagnosis



Current treatment


Pain 1 Anxiety

Pain 2 Depression




Mobility [fatigue]





Patient

Carer

Last updated



SCHOLARLY PAPER

ABSTRACT




















dewarnursingubcca





SCHOLARLY PAPER

34

LITERATURE REVIEW













SCHOLARLY PAPER

35














SCHOLARLY PAPER

36













SCHOLARLY PAPER

37




















































SCHOLARLY PAPER

38









ABSTRACT













Conclusions







workforce planning

Acknowledgements















SCHOLARLY PAPER

39













INTRODUCTION















have been used



SCHOLARLY PAPER

40














Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL








RESEARCH PAPER

12















DISCUSSION







RESEARCH PAPER

13















































RESEARCH PAPER

14


jcioffiuwseduau



RESEARCH PAPER

ABSTRACT













INTRODUCTION









METHOD










RESEARCH PAPER

16


Characteristic f=




































RESEARCH PAPER

17





















RESEARCH PAPER

18


























RESEARCH PAPER

19


















RESEARCH PAPER

20


ABSTRACT











INTRODUCTION







wdayucolacnz




RESEARCH PAPER




















RESEARCH PAPER

22



Restricted roles














RESEARCH PAPER

23





REFRAMING



Carrying on

Being supported




















RESEARCH PAPER

24






































RESEARCH PAPER

25























RESEARCH PAPER

26


ABSTRACT

Objective


Design

















johnfibhsorgau





RESEARCH PAPER






bull communication







bull history

















RESEARCH PAPER

28




METHOD

Objective


Design










used in this study










RESEARCH PAPER

29



LIMITATIONS




















RESEARCH PAPER

30










































RESEARCH PAPER

31


RESEARCH PAPER

32


Name

Address

Phone

UR No DOB


GP Name Phone Fax

NOK Phone

Specialist

Brief History

Primary Diagnosis

Secondary Diagnosis



Current treatment


Pain 1 Anxiety

Pain 2 Depression




Mobility [fatigue]





Patient

Carer

Last updated



SCHOLARLY PAPER

ABSTRACT




















dewarnursingubcca





SCHOLARLY PAPER

34

LITERATURE REVIEW













SCHOLARLY PAPER

35














SCHOLARLY PAPER

36













SCHOLARLY PAPER

37




















































SCHOLARLY PAPER

38









ABSTRACT













Conclusions







workforce planning

Acknowledgements















SCHOLARLY PAPER

39













INTRODUCTION















have been used



SCHOLARLY PAPER

40














Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL








RESEARCH PAPER

13















































RESEARCH PAPER

14


jcioffiuwseduau



RESEARCH PAPER

ABSTRACT













INTRODUCTION









METHOD










RESEARCH PAPER

16


Characteristic f=




































RESEARCH PAPER

17





















RESEARCH PAPER

18


























RESEARCH PAPER

19


















RESEARCH PAPER

20


ABSTRACT











INTRODUCTION







wdayucolacnz




RESEARCH PAPER




















RESEARCH PAPER

22



Restricted roles














RESEARCH PAPER

23





REFRAMING



Carrying on

Being supported




















RESEARCH PAPER

24






































RESEARCH PAPER

25























RESEARCH PAPER

26


ABSTRACT

Objective


Design

















johnfibhsorgau





RESEARCH PAPER






bull communication







bull history

















RESEARCH PAPER

28




METHOD

Objective


Design










used in this study










RESEARCH PAPER

29



LIMITATIONS




















RESEARCH PAPER

30










































RESEARCH PAPER

31


RESEARCH PAPER

32


Name

Address

Phone

UR No DOB


GP Name Phone Fax

NOK Phone

Specialist

Brief History

Primary Diagnosis

Secondary Diagnosis



Current treatment


Pain 1 Anxiety

Pain 2 Depression




Mobility [fatigue]





Patient

Carer

Last updated



SCHOLARLY PAPER

ABSTRACT




















dewarnursingubcca





SCHOLARLY PAPER

34

LITERATURE REVIEW













SCHOLARLY PAPER

35














SCHOLARLY PAPER

36













SCHOLARLY PAPER

37




















































SCHOLARLY PAPER

38









ABSTRACT













Conclusions







workforce planning

Acknowledgements















SCHOLARLY PAPER

39













INTRODUCTION















have been used



SCHOLARLY PAPER

40














Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL




































RESEARCH PAPER

14


jcioffiuwseduau



RESEARCH PAPER

ABSTRACT













INTRODUCTION









METHOD










RESEARCH PAPER

16


Characteristic f=




































RESEARCH PAPER

17





















RESEARCH PAPER

18


























RESEARCH PAPER

19


















RESEARCH PAPER

20


ABSTRACT











INTRODUCTION







wdayucolacnz




RESEARCH PAPER




















RESEARCH PAPER

22



Restricted roles














RESEARCH PAPER

23





REFRAMING



Carrying on

Being supported




















RESEARCH PAPER

24






































RESEARCH PAPER

25























RESEARCH PAPER

26


ABSTRACT

Objective


Design

















johnfibhsorgau





RESEARCH PAPER






bull communication







bull history

















RESEARCH PAPER

28




METHOD

Objective


Design










used in this study










RESEARCH PAPER

29



LIMITATIONS




















RESEARCH PAPER

30










































RESEARCH PAPER

31


RESEARCH PAPER

32


Name

Address

Phone

UR No DOB


GP Name Phone Fax

NOK Phone

Specialist

Brief History

Primary Diagnosis

Secondary Diagnosis



Current treatment


Pain 1 Anxiety

Pain 2 Depression




Mobility [fatigue]





Patient

Carer

Last updated



SCHOLARLY PAPER

ABSTRACT




















dewarnursingubcca





SCHOLARLY PAPER

34

LITERATURE REVIEW













SCHOLARLY PAPER

35














SCHOLARLY PAPER

36













SCHOLARLY PAPER

37




















































SCHOLARLY PAPER

38









ABSTRACT













Conclusions







workforce planning

Acknowledgements















SCHOLARLY PAPER

39













INTRODUCTION















have been used



SCHOLARLY PAPER

40














Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL








jcioffiuwseduau



RESEARCH PAPER

ABSTRACT













INTRODUCTION









METHOD










RESEARCH PAPER

16


Characteristic f=




































RESEARCH PAPER

17





















RESEARCH PAPER

18


























RESEARCH PAPER

19


















RESEARCH PAPER

20


ABSTRACT











INTRODUCTION







wdayucolacnz




RESEARCH PAPER




















RESEARCH PAPER

22



Restricted roles














RESEARCH PAPER

23





REFRAMING



Carrying on

Being supported




















RESEARCH PAPER

24






































RESEARCH PAPER

25























RESEARCH PAPER

26


ABSTRACT

Objective


Design

















johnfibhsorgau





RESEARCH PAPER






bull communication







bull history

















RESEARCH PAPER

28




METHOD

Objective


Design










used in this study










RESEARCH PAPER

29



LIMITATIONS




















RESEARCH PAPER

30










































RESEARCH PAPER

31


RESEARCH PAPER

32


Name

Address

Phone

UR No DOB


GP Name Phone Fax

NOK Phone

Specialist

Brief History

Primary Diagnosis

Secondary Diagnosis



Current treatment


Pain 1 Anxiety

Pain 2 Depression




Mobility [fatigue]





Patient

Carer

Last updated



SCHOLARLY PAPER

ABSTRACT




















dewarnursingubcca





SCHOLARLY PAPER

34

LITERATURE REVIEW













SCHOLARLY PAPER

35














SCHOLARLY PAPER

36













SCHOLARLY PAPER

37




















































SCHOLARLY PAPER

38









ABSTRACT













Conclusions







workforce planning

Acknowledgements















SCHOLARLY PAPER

39













INTRODUCTION















have been used



SCHOLARLY PAPER

40














Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL









METHOD










RESEARCH PAPER

16


Characteristic f=




































RESEARCH PAPER

17





















RESEARCH PAPER

18


























RESEARCH PAPER

19


















RESEARCH PAPER

20


ABSTRACT











INTRODUCTION







wdayucolacnz




RESEARCH PAPER




















RESEARCH PAPER

22



Restricted roles














RESEARCH PAPER

23





REFRAMING



Carrying on

Being supported




















RESEARCH PAPER

24






































RESEARCH PAPER

25























RESEARCH PAPER

26


ABSTRACT

Objective


Design

















johnfibhsorgau





RESEARCH PAPER






bull communication







bull history

















RESEARCH PAPER

28




METHOD

Objective


Design










used in this study










RESEARCH PAPER

29



LIMITATIONS




















RESEARCH PAPER

30










































RESEARCH PAPER

31


RESEARCH PAPER

32


Name

Address

Phone

UR No DOB


GP Name Phone Fax

NOK Phone

Specialist

Brief History

Primary Diagnosis

Secondary Diagnosis



Current treatment


Pain 1 Anxiety

Pain 2 Depression




Mobility [fatigue]





Patient

Carer

Last updated



SCHOLARLY PAPER

ABSTRACT




















dewarnursingubcca





SCHOLARLY PAPER

34

LITERATURE REVIEW













SCHOLARLY PAPER

35














SCHOLARLY PAPER

36













SCHOLARLY PAPER

37




















































SCHOLARLY PAPER

38









ABSTRACT













Conclusions







workforce planning

Acknowledgements















SCHOLARLY PAPER

39













INTRODUCTION















have been used



SCHOLARLY PAPER

40














Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL

































RESEARCH PAPER

17





















RESEARCH PAPER

18


























RESEARCH PAPER

19


















RESEARCH PAPER

20


ABSTRACT











INTRODUCTION







wdayucolacnz




RESEARCH PAPER




















RESEARCH PAPER

22



Restricted roles














RESEARCH PAPER

23





REFRAMING



Carrying on

Being supported




















RESEARCH PAPER

24






































RESEARCH PAPER

25























RESEARCH PAPER

26


ABSTRACT

Objective


Design

















johnfibhsorgau





RESEARCH PAPER






bull communication







bull history

















RESEARCH PAPER

28




METHOD

Objective


Design










used in this study










RESEARCH PAPER

29



LIMITATIONS




















RESEARCH PAPER

30










































RESEARCH PAPER

31


RESEARCH PAPER

32


Name

Address

Phone

UR No DOB


GP Name Phone Fax

NOK Phone

Specialist

Brief History

Primary Diagnosis

Secondary Diagnosis



Current treatment


Pain 1 Anxiety

Pain 2 Depression




Mobility [fatigue]





Patient

Carer

Last updated



SCHOLARLY PAPER

ABSTRACT




















dewarnursingubcca





SCHOLARLY PAPER

34

LITERATURE REVIEW













SCHOLARLY PAPER

35














SCHOLARLY PAPER

36













SCHOLARLY PAPER

37




















































SCHOLARLY PAPER

38









ABSTRACT













Conclusions







workforce planning

Acknowledgements















SCHOLARLY PAPER

39













INTRODUCTION















have been used



SCHOLARLY PAPER

40














Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL



























RESEARCH PAPER

18


























RESEARCH PAPER

19


















RESEARCH PAPER

20


ABSTRACT











INTRODUCTION







wdayucolacnz




RESEARCH PAPER




















RESEARCH PAPER

22



Restricted roles














RESEARCH PAPER

23





REFRAMING



Carrying on

Being supported




















RESEARCH PAPER

24






































RESEARCH PAPER

25























RESEARCH PAPER

26


ABSTRACT

Objective


Design

















johnfibhsorgau





RESEARCH PAPER






bull communication







bull history

















RESEARCH PAPER

28




METHOD

Objective


Design










used in this study










RESEARCH PAPER

29



LIMITATIONS




















RESEARCH PAPER

30










































RESEARCH PAPER

31


RESEARCH PAPER

32


Name

Address

Phone

UR No DOB


GP Name Phone Fax

NOK Phone

Specialist

Brief History

Primary Diagnosis

Secondary Diagnosis



Current treatment


Pain 1 Anxiety

Pain 2 Depression




Mobility [fatigue]





Patient

Carer

Last updated



SCHOLARLY PAPER

ABSTRACT




















dewarnursingubcca





SCHOLARLY PAPER

34

LITERATURE REVIEW













SCHOLARLY PAPER

35














SCHOLARLY PAPER

36













SCHOLARLY PAPER

37




















































SCHOLARLY PAPER

38









ABSTRACT













Conclusions







workforce planning

Acknowledgements















SCHOLARLY PAPER

39













INTRODUCTION















have been used



SCHOLARLY PAPER

40














Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL
































RESEARCH PAPER

19


















RESEARCH PAPER

20


ABSTRACT











INTRODUCTION







wdayucolacnz




RESEARCH PAPER




















RESEARCH PAPER

22



Restricted roles














RESEARCH PAPER

23





REFRAMING



Carrying on

Being supported




















RESEARCH PAPER

24






































RESEARCH PAPER

25























RESEARCH PAPER

26


ABSTRACT

Objective


Design

















johnfibhsorgau





RESEARCH PAPER






bull communication







bull history

















RESEARCH PAPER

28




METHOD

Objective


Design










used in this study










RESEARCH PAPER

29



LIMITATIONS




















RESEARCH PAPER

30










































RESEARCH PAPER

31


RESEARCH PAPER

32


Name

Address

Phone

UR No DOB


GP Name Phone Fax

NOK Phone

Specialist

Brief History

Primary Diagnosis

Secondary Diagnosis



Current treatment


Pain 1 Anxiety

Pain 2 Depression




Mobility [fatigue]





Patient

Carer

Last updated



SCHOLARLY PAPER

ABSTRACT




















dewarnursingubcca





SCHOLARLY PAPER

34

LITERATURE REVIEW













SCHOLARLY PAPER

35














SCHOLARLY PAPER

36













SCHOLARLY PAPER

37




















































SCHOLARLY PAPER

38









ABSTRACT













Conclusions







workforce planning

Acknowledgements















SCHOLARLY PAPER

39













INTRODUCTION















have been used



SCHOLARLY PAPER

40














Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL
























RESEARCH PAPER

20


ABSTRACT











INTRODUCTION







wdayucolacnz




RESEARCH PAPER




















RESEARCH PAPER

22



Restricted roles














RESEARCH PAPER

23





REFRAMING



Carrying on

Being supported




















RESEARCH PAPER

24






































RESEARCH PAPER

25























RESEARCH PAPER

26


ABSTRACT

Objective


Design

















johnfibhsorgau





RESEARCH PAPER






bull communication







bull history

















RESEARCH PAPER

28




METHOD

Objective


Design










used in this study










RESEARCH PAPER

29



LIMITATIONS




















RESEARCH PAPER

30










































RESEARCH PAPER

31


RESEARCH PAPER

32


Name

Address

Phone

UR No DOB


GP Name Phone Fax

NOK Phone

Specialist

Brief History

Primary Diagnosis

Secondary Diagnosis



Current treatment


Pain 1 Anxiety

Pain 2 Depression




Mobility [fatigue]





Patient

Carer

Last updated



SCHOLARLY PAPER

ABSTRACT




















dewarnursingubcca





SCHOLARLY PAPER

34

LITERATURE REVIEW













SCHOLARLY PAPER

35














SCHOLARLY PAPER

36













SCHOLARLY PAPER

37




















































SCHOLARLY PAPER

38









ABSTRACT













Conclusions







workforce planning

Acknowledgements















SCHOLARLY PAPER

39













INTRODUCTION















have been used



SCHOLARLY PAPER

40














Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL








ABSTRACT











INTRODUCTION







wdayucolacnz




RESEARCH PAPER




















RESEARCH PAPER

22



Restricted roles














RESEARCH PAPER

23





REFRAMING



Carrying on

Being supported




















RESEARCH PAPER

24






































RESEARCH PAPER

25























RESEARCH PAPER

26


ABSTRACT

Objective


Design

















johnfibhsorgau





RESEARCH PAPER






bull communication







bull history

















RESEARCH PAPER

28




METHOD

Objective


Design










used in this study










RESEARCH PAPER

29



LIMITATIONS




















RESEARCH PAPER

30










































RESEARCH PAPER

31


RESEARCH PAPER

32


Name

Address

Phone

UR No DOB


GP Name Phone Fax

NOK Phone

Specialist

Brief History

Primary Diagnosis

Secondary Diagnosis



Current treatment


Pain 1 Anxiety

Pain 2 Depression




Mobility [fatigue]





Patient

Carer

Last updated



SCHOLARLY PAPER

ABSTRACT




















dewarnursingubcca





SCHOLARLY PAPER

34

LITERATURE REVIEW













SCHOLARLY PAPER

35














SCHOLARLY PAPER

36













SCHOLARLY PAPER

37




















































SCHOLARLY PAPER

38









ABSTRACT













Conclusions







workforce planning

Acknowledgements















SCHOLARLY PAPER

39













INTRODUCTION















have been used



SCHOLARLY PAPER

40














Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL

























RESEARCH PAPER

22



Restricted roles














RESEARCH PAPER

23





REFRAMING



Carrying on

Being supported




















RESEARCH PAPER

24






































RESEARCH PAPER

25























RESEARCH PAPER

26


ABSTRACT

Objective


Design

















johnfibhsorgau





RESEARCH PAPER






bull communication







bull history

















RESEARCH PAPER

28




METHOD

Objective


Design










used in this study










RESEARCH PAPER

29



LIMITATIONS




















RESEARCH PAPER

30










































RESEARCH PAPER

31


RESEARCH PAPER

32


Name

Address

Phone

UR No DOB


GP Name Phone Fax

NOK Phone

Specialist

Brief History

Primary Diagnosis

Secondary Diagnosis



Current treatment


Pain 1 Anxiety

Pain 2 Depression




Mobility [fatigue]





Patient

Carer

Last updated



SCHOLARLY PAPER

ABSTRACT




















dewarnursingubcca





SCHOLARLY PAPER

34

LITERATURE REVIEW













SCHOLARLY PAPER

35














SCHOLARLY PAPER

36













SCHOLARLY PAPER

37




















































SCHOLARLY PAPER

38









ABSTRACT













Conclusions







workforce planning

Acknowledgements















SCHOLARLY PAPER

39













INTRODUCTION















have been used



SCHOLARLY PAPER

40














Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL









Restricted roles














RESEARCH PAPER

23





REFRAMING



Carrying on

Being supported




















RESEARCH PAPER

24






































RESEARCH PAPER

25























RESEARCH PAPER

26


ABSTRACT

Objective


Design

















johnfibhsorgau





RESEARCH PAPER






bull communication







bull history

















RESEARCH PAPER

28




METHOD

Objective


Design










used in this study










RESEARCH PAPER

29



LIMITATIONS




















RESEARCH PAPER

30










































RESEARCH PAPER

31


RESEARCH PAPER

32


Name

Address

Phone

UR No DOB


GP Name Phone Fax

NOK Phone

Specialist

Brief History

Primary Diagnosis

Secondary Diagnosis



Current treatment


Pain 1 Anxiety

Pain 2 Depression




Mobility [fatigue]





Patient

Carer

Last updated



SCHOLARLY PAPER

ABSTRACT




















dewarnursingubcca





SCHOLARLY PAPER

34

LITERATURE REVIEW













SCHOLARLY PAPER

35














SCHOLARLY PAPER

36













SCHOLARLY PAPER

37




















































SCHOLARLY PAPER

38









ABSTRACT













Conclusions







workforce planning

Acknowledgements















SCHOLARLY PAPER

39













INTRODUCTION















have been used



SCHOLARLY PAPER

40














Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL
























RESEARCH PAPER

24






































RESEARCH PAPER

25























RESEARCH PAPER

26


ABSTRACT

Objective


Design

















johnfibhsorgau





RESEARCH PAPER






bull communication







bull history

















RESEARCH PAPER

28




METHOD

Objective


Design










used in this study










RESEARCH PAPER

29



LIMITATIONS




















RESEARCH PAPER

30










































RESEARCH PAPER

31


RESEARCH PAPER

32


Name

Address

Phone

UR No DOB


GP Name Phone Fax

NOK Phone

Specialist

Brief History

Primary Diagnosis

Secondary Diagnosis



Current treatment


Pain 1 Anxiety

Pain 2 Depression




Mobility [fatigue]





Patient

Carer

Last updated



SCHOLARLY PAPER

ABSTRACT




















dewarnursingubcca





SCHOLARLY PAPER

34

LITERATURE REVIEW













SCHOLARLY PAPER

35














SCHOLARLY PAPER

36













SCHOLARLY PAPER

37




















































SCHOLARLY PAPER

38









ABSTRACT













Conclusions







workforce planning

Acknowledgements















SCHOLARLY PAPER

39













INTRODUCTION















have been used



SCHOLARLY PAPER

40














Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL












































RESEARCH PAPER

25























RESEARCH PAPER

26


ABSTRACT

Objective


Design

















johnfibhsorgau





RESEARCH PAPER






bull communication







bull history

















RESEARCH PAPER

28




METHOD

Objective


Design










used in this study










RESEARCH PAPER

29



LIMITATIONS




















RESEARCH PAPER

30










































RESEARCH PAPER

31


RESEARCH PAPER

32


Name

Address

Phone

UR No DOB


GP Name Phone Fax

NOK Phone

Specialist

Brief History

Primary Diagnosis

Secondary Diagnosis



Current treatment


Pain 1 Anxiety

Pain 2 Depression




Mobility [fatigue]





Patient

Carer

Last updated



SCHOLARLY PAPER

ABSTRACT




















dewarnursingubcca





SCHOLARLY PAPER

34

LITERATURE REVIEW













SCHOLARLY PAPER

35














SCHOLARLY PAPER

36













SCHOLARLY PAPER

37




















































SCHOLARLY PAPER

38









ABSTRACT













Conclusions







workforce planning

Acknowledgements















SCHOLARLY PAPER

39













INTRODUCTION















have been used



SCHOLARLY PAPER

40














Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL





























RESEARCH PAPER

26


ABSTRACT

Objective


Design

















johnfibhsorgau





RESEARCH PAPER






bull communication







bull history

















RESEARCH PAPER

28




METHOD

Objective


Design










used in this study










RESEARCH PAPER

29



LIMITATIONS




















RESEARCH PAPER

30










































RESEARCH PAPER

31


RESEARCH PAPER

32


Name

Address

Phone

UR No DOB


GP Name Phone Fax

NOK Phone

Specialist

Brief History

Primary Diagnosis

Secondary Diagnosis



Current treatment


Pain 1 Anxiety

Pain 2 Depression




Mobility [fatigue]





Patient

Carer

Last updated



SCHOLARLY PAPER

ABSTRACT




















dewarnursingubcca





SCHOLARLY PAPER

34

LITERATURE REVIEW













SCHOLARLY PAPER

35














SCHOLARLY PAPER

36













SCHOLARLY PAPER

37




















































SCHOLARLY PAPER

38









ABSTRACT













Conclusions







workforce planning

Acknowledgements















SCHOLARLY PAPER

39













INTRODUCTION















have been used



SCHOLARLY PAPER

40














Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL








ABSTRACT

Objective


Design

















johnfibhsorgau





RESEARCH PAPER






bull communication







bull history

















RESEARCH PAPER

28




METHOD

Objective


Design










used in this study










RESEARCH PAPER

29



LIMITATIONS




















RESEARCH PAPER

30










































RESEARCH PAPER

31


RESEARCH PAPER

32


Name

Address

Phone

UR No DOB


GP Name Phone Fax

NOK Phone

Specialist

Brief History

Primary Diagnosis

Secondary Diagnosis



Current treatment


Pain 1 Anxiety

Pain 2 Depression




Mobility [fatigue]





Patient

Carer

Last updated



SCHOLARLY PAPER

ABSTRACT




















dewarnursingubcca





SCHOLARLY PAPER

34

LITERATURE REVIEW













SCHOLARLY PAPER

35














SCHOLARLY PAPER

36













SCHOLARLY PAPER

37




















































SCHOLARLY PAPER

38









ABSTRACT













Conclusions







workforce planning

Acknowledgements















SCHOLARLY PAPER

39













INTRODUCTION















have been used



SCHOLARLY PAPER

40














Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL











bull communication







bull history

















RESEARCH PAPER

28




METHOD

Objective


Design










used in this study










RESEARCH PAPER

29



LIMITATIONS




















RESEARCH PAPER

30










































RESEARCH PAPER

31


RESEARCH PAPER

32


Name

Address

Phone

UR No DOB


GP Name Phone Fax

NOK Phone

Specialist

Brief History

Primary Diagnosis

Secondary Diagnosis



Current treatment


Pain 1 Anxiety

Pain 2 Depression




Mobility [fatigue]





Patient

Carer

Last updated



SCHOLARLY PAPER

ABSTRACT




















dewarnursingubcca





SCHOLARLY PAPER

34

LITERATURE REVIEW













SCHOLARLY PAPER

35














SCHOLARLY PAPER

36













SCHOLARLY PAPER

37




















































SCHOLARLY PAPER

38









ABSTRACT













Conclusions







workforce planning

Acknowledgements















SCHOLARLY PAPER

39













INTRODUCTION















have been used



SCHOLARLY PAPER

40














Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL










METHOD

Objective


Design










used in this study










RESEARCH PAPER

29



LIMITATIONS




















RESEARCH PAPER

30










































RESEARCH PAPER

31


RESEARCH PAPER

32


Name

Address

Phone

UR No DOB


GP Name Phone Fax

NOK Phone

Specialist

Brief History

Primary Diagnosis

Secondary Diagnosis



Current treatment


Pain 1 Anxiety

Pain 2 Depression




Mobility [fatigue]





Patient

Carer

Last updated



SCHOLARLY PAPER

ABSTRACT




















dewarnursingubcca





SCHOLARLY PAPER

34

LITERATURE REVIEW













SCHOLARLY PAPER

35














SCHOLARLY PAPER

36













SCHOLARLY PAPER

37




















































SCHOLARLY PAPER

38









ABSTRACT













Conclusions







workforce planning

Acknowledgements















SCHOLARLY PAPER

39













INTRODUCTION















have been used



SCHOLARLY PAPER

40














Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL









LIMITATIONS




















RESEARCH PAPER

30










































RESEARCH PAPER

31


RESEARCH PAPER

32


Name

Address

Phone

UR No DOB


GP Name Phone Fax

NOK Phone

Specialist

Brief History

Primary Diagnosis

Secondary Diagnosis



Current treatment


Pain 1 Anxiety

Pain 2 Depression




Mobility [fatigue]





Patient

Carer

Last updated



SCHOLARLY PAPER

ABSTRACT




















dewarnursingubcca





SCHOLARLY PAPER

34

LITERATURE REVIEW













SCHOLARLY PAPER

35














SCHOLARLY PAPER

36













SCHOLARLY PAPER

37




















































SCHOLARLY PAPER

38









ABSTRACT













Conclusions







workforce planning

Acknowledgements















SCHOLARLY PAPER

39













INTRODUCTION















have been used



SCHOLARLY PAPER

40














Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL
















































RESEARCH PAPER

31


RESEARCH PAPER

32


Name

Address

Phone

UR No DOB


GP Name Phone Fax

NOK Phone

Specialist

Brief History

Primary Diagnosis

Secondary Diagnosis



Current treatment


Pain 1 Anxiety

Pain 2 Depression




Mobility [fatigue]





Patient

Carer

Last updated



SCHOLARLY PAPER

ABSTRACT




















dewarnursingubcca





SCHOLARLY PAPER

34

LITERATURE REVIEW













SCHOLARLY PAPER

35














SCHOLARLY PAPER

36













SCHOLARLY PAPER

37




















































SCHOLARLY PAPER

38









ABSTRACT













Conclusions







workforce planning

Acknowledgements















SCHOLARLY PAPER

39













INTRODUCTION















have been used



SCHOLARLY PAPER

40














Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL








RESEARCH PAPER

32


Name

Address

Phone

UR No DOB


GP Name Phone Fax

NOK Phone

Specialist

Brief History

Primary Diagnosis

Secondary Diagnosis



Current treatment


Pain 1 Anxiety

Pain 2 Depression




Mobility [fatigue]





Patient

Carer

Last updated



SCHOLARLY PAPER

ABSTRACT




















dewarnursingubcca





SCHOLARLY PAPER

34

LITERATURE REVIEW













SCHOLARLY PAPER

35














SCHOLARLY PAPER

36













SCHOLARLY PAPER

37




















































SCHOLARLY PAPER

38









ABSTRACT













Conclusions







workforce planning

Acknowledgements















SCHOLARLY PAPER

39













INTRODUCTION















have been used



SCHOLARLY PAPER

40














Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL








SCHOLARLY PAPER

ABSTRACT




















dewarnursingubcca





SCHOLARLY PAPER

34

LITERATURE REVIEW













SCHOLARLY PAPER

35














SCHOLARLY PAPER

36













SCHOLARLY PAPER

37




















































SCHOLARLY PAPER

38









ABSTRACT













Conclusions







workforce planning

Acknowledgements















SCHOLARLY PAPER

39













INTRODUCTION















have been used



SCHOLARLY PAPER

40














Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL








SCHOLARLY PAPER

34

LITERATURE REVIEW













SCHOLARLY PAPER

35














SCHOLARLY PAPER

36













SCHOLARLY PAPER

37




















































SCHOLARLY PAPER

38









ABSTRACT













Conclusions







workforce planning

Acknowledgements















SCHOLARLY PAPER

39













INTRODUCTION















have been used



SCHOLARLY PAPER

40














Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL







SCHOLARLY PAPER

35














SCHOLARLY PAPER

36













SCHOLARLY PAPER

37




















































SCHOLARLY PAPER

38









ABSTRACT













Conclusions







workforce planning

Acknowledgements















SCHOLARLY PAPER

39













INTRODUCTION















have been used



SCHOLARLY PAPER

40














Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL








SCHOLARLY PAPER

36













SCHOLARLY PAPER

37




















































SCHOLARLY PAPER

38









ABSTRACT













Conclusions







workforce planning

Acknowledgements















SCHOLARLY PAPER

39













INTRODUCTION















have been used



SCHOLARLY PAPER

40














Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL








SCHOLARLY PAPER

37




















































SCHOLARLY PAPER

38









ABSTRACT













Conclusions







workforce planning

Acknowledgements















SCHOLARLY PAPER

39













INTRODUCTION















have been used



SCHOLARLY PAPER

40














Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL








SCHOLARLY PAPER

38









ABSTRACT













Conclusions







workforce planning

Acknowledgements















SCHOLARLY PAPER

39













INTRODUCTION















have been used



SCHOLARLY PAPER

40














Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL







ABSTRACT













Conclusions







workforce planning

Acknowledgements















SCHOLARLY PAPER

39













INTRODUCTION















have been used



SCHOLARLY PAPER

40














Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL








INTRODUCTION















have been used



SCHOLARLY PAPER

40














Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL




















Results






SCHOLARLY PAPER

41













SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL



















SCHOLARLY PAPER

42



1 NBSA $175 $105

2 QNC $129 $85

3 VIC $120 $80$120 after March 31

4 NSW $60 $50

5 TAS $200 $120

6 WA $120 $90$245 for 3 years

Territories

7 NT $75 $50

8 ACT $80 $45

TOTAL $959 $625

StateTerritory




StateTerritory

Registration status





States

1 NBSA Full Yes NA


3 VIC Full Yes Yes


5 TAS Full Yes Yes


Territories

7 NT Full Yes Yes

8 ACT Full Yes No








SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL














SCHOLARLY PAPER

43

State Due date

ACT March 31st

QLD June 30th

TAS August 31st

SA August 31st

NT September 30th

NSW November 30th

VIC December 31st

































SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL




























SCHOLARLY PAPER

44


SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL








SCHOLARLY PAPER

45




















FROM THE EDITOR

GUEST EDITORIAL







from the editor Ð dr jackie jones rn phd Ôsoul ... - ajan · australian journal of advanced...

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